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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804034
Report Date: 01/26/2023
Date Signed: 02/09/2023 10:20:58 AM

Document Has Been Signed on 02/09/2023 10:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:TUSCAN MANOR E LLCFACILITY NUMBER:
496804034
ADMINISTRATOR:ARIZMEDI, EUFRASIAFACILITY TYPE:
740
ADDRESS:1920 GROSSE AVENUETELEPHONE:
(707) 328-2546
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 6DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Licensee, Eufrasia (Oliva) Garcia ArizmendiTIME COMPLETED:
12:55 PM
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Amended*

Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by a caregiver. Licensee, Eufrasia (Oliva) Garcia Arizmendi arrived later. The inspection is focused on the Infection Control procedures and practices of this facility

Upon arrival, LPA observed posters outside notifying visitors that masks must be worn in the facility. Once inside, LPA observed a screening station near the entrance that included a visitor sign in and thermometer. LPA confirmed that facility is no longer requiring vaccination verification per guidance. LPA initiated a walk-through of the facility around 11:30 am and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. Per Licensee, facility continues to screen staff and residents.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE. Licensee has initiated the process of having staff N-95 fit tested.

Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguisher was last serviced December 2022. Three of eleven smoke detectors were not operational when tested. Carbon Monoxide detector was tested and operational.

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TUSCAN MANOR E LLC
FACILITY NUMBER: 496804034
VISIT DATE: 01/26/2023
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Continued from LIC809C

Facility has submitted their Emergency Disaster Plan, Infection Control Plan and Mitigation Plan.



Licensee/Administrator to submit updates of the following documents by 2/26/2023:
LIC 308 Designated Administrator (if applicable)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (review and update if changes)
Liability Insurance


No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC809 (FAS) - (06/04)
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