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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002953
Report Date: 01/30/2023
Date Signed: 01/30/2023 03:41:23 PM


Document Has Been Signed on 01/30/2023 03:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:TUSCAN PALMS HOME CARE LLCFACILITY NUMBER:
345002953
ADMINISTRATOR:TIMIS, ALEXANDRU VICTORFACILITY TYPE:
740
ADDRESS:7921 ALMA MESA WAYTELEPHONE:
(279) 529-2363
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 6DATE:
01/30/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Alexandru "Alex" Timis, Administrator TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived announced to conduct a pre-licensing inspection for a change in ownership. LPA met with Alexandru "Alex" Timis, Administrator, and current
Licensee/Administrator, Esther Bolthausen. LPA observed caregiver, Angela Campbell, also present. LPA observed (4) residents to be resting in their rooms and was advised (2) residents were currently out of the facility. The facility is currently licensed for (5) non-ambulatory residents, (1) ambulatory resident and has a hospice waiver for (3). Currently, there is (1) resident on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 protocols. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility, and wore the following Personal Protective Equipment (PPE): surgical mask.

LPA and Administrators toured the interior and exterior of the facility including the common areas, resident bedrooms (6), resident bathrooms (3.5), kitchen, staff rooms and laundry area. All resident rooms are private and have a sliding exit glass door. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels, trash cans with a lid and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, locked sharps and medications in/near the kitchen and locked toxins in the laundry. LPA observed the inside temperature to be 71*F. Fire extinguisher was last serviced on 2/11/2022. LPA observed the smoke/monoxide alarms to be working. LPA observed sufficient PPE supplies on hand. LPA observed games, movies and books on hand as well as sufficient linens/blankets/towels. LPA observed alarms on all exit doors and (1) exterior gate to be unlocked from the inside. LPA observed all required postings to be posted and RCFE Administrator certificate # 6004832740- exp 11/4/23. LPA observed (2) other current RCFE Administrator Designee certificates to be posted. LPA discussed how the current Licensee notified residents/representatives about ownership change and paperwork to be completed upon ownership change. LPA reviewed (1) resident and staff file and observed them to be organized and contain current documentation. Discussed vaccination status of residents and staff and a flyer was provided. Component III was reviewed during today’s inspection. It appears the facility is in substantial compliance and there are no deficiencies being noted today.

Exit interview done. Copy of report provided to Administrator and application unit to be notified.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
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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