306004543-5-28-2021-22-AS-SHAD-C3FUPF-20210528154528

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004543
Report Date: 05/28/2021
Date Signed: 05/28/2021 03:45:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	GOLDEN TUSCANY CARE		FACILITY NUMBER:	306004543
ADMINISTRATOR:	DANIEL RESCIA		FACILITY TYPE:	740
ADDRESS:	2825 E. DUTCH AVENUE		TELEPHONE:	(714) 234-6348
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92806
CAPACITY:	6	CENSUS: 4	DATE:	05/28/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Evangeline Bulaon		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Staff Member (Staff) Evangeline Bulaon and discussed the purpose of the inspection. Administrator (AD) Daniel Rescia was not present during the inspection. During the inspection, LPA and Staff conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: LPA and Staff observed there were 2 staff present, wearing PPE. LPA observed 4 residents were present. LPA confirmed all residents were doing well. LPA inspected common areas, resident rooms, garage, and kitchen, and observed they were clean and organized. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction. During the inspection, LPA and Staff observed the attached garage was not locked or lockable and contained toxins accessible to residents, including laundry detergent, automotive chemicals, and cleaning supplies. In the kitchen, LPA and Staff observed knives and toxins, including cleaning supplies, locked under the sink, but the key to the lock was accessible to residents on the sink countertop. In the backyard, LPA and Staff observed tools and toxins, including laundry detergent and cleaning supplies, available to residents on an open shelf behind a gate that was not locked or lockable. During the inspection, Staff reversed the lock on the garage door which allowed the garage door to be locked, removed and concealed the lock for the cabinet under the sink, and relocated the tools and toxins in the backyard to the locked garage and a locked storage cabinet in the back yard. (Page 1)

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GOLDEN TUSCANY CARE	FACILITY NUMBER: 306004543
	VISIT DATE: 05/28/2021

NARRATIVE

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LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, communication and emergency plan, and dementia. LPA provided technical assistance regarding screening, surveillance testing, visitation, resident outings, COVID-19 signs, and N95 fit testing. LPA requested and reviewed resident roster, staff roster, staff files, emergency plan, and COVID-19 mitigation plan.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.

(Page 2)

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC809 (FAS) - (06/04)

Page: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GOLDEN TUSCANY CARE	FACILITY NUMBER: 306004543
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

87303 Maintenance and Operation: (a) The facility shall be clean, safe.... Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents... This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not ensure toxins, knives, and other dangerous items were inaccessible to residents in 3 out of 14 rooms/areas which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/29/2021
	Plan of Correction
1 2 3 4	Licensee immediately secured the toxins, knives, medications, and other dangerous items during today's inspection

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Marina Stanic	TELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC809 (FAS) - (06/04)

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