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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005720
Report Date: 06/21/2021
Date Signed: 06/21/2021 01:12:24 PM

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 CAREFACILITY NUMBER:
347005720
ADMINISTRATOR:BOLTHAUSEN, ESTHER LAZAFACILITY TYPE:
740
ADDRESS:7921 ALMA MESA WAYTELEPHONE:
(916) 224-3148
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 6DATE:
06/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 6/21/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Rojo Mittelholzer (Staff) and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by staff. Upon entering facility, staff contacted Esther Laza (Admin) to have her be present during the inspection.

LPA and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) of six (6) resident bedrooms, three (3) of three (3) staff rooms, four (4) of four (4) bathrooms, kitchen, garage, storage shed and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and admin completed the infection control domain and facility was found to be in substantial compliance at this time. LPA is requesting the following doucments to be provided to Community Care Licensing (CCLD) by COB 6/30/2021: Personnel Report (LIC 500); Designation of Administrative Responsibility (LIC 308); Affidavit Regarding Client Cash Resources (LIC 400); Current Admin Certificate; Emergency Disaster Plan (LIC 610E).

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
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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