496804034-3-26-2024-21-AS-MCUA-D3QUBD-20240326152609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804034
Report Date: 03/26/2024
Date Signed: 03/26/2024 03:26:20 PM

Document Has Been Signed on 03/26/2024 03:26 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	TUSCAN MANOR E LLC		FACILITY NUMBER:	496804034
ADMINISTRATOR:	ARIZMEDI, EUFRASIA		FACILITY TYPE:	740
ADDRESS:	1920 GROSSE AVENUE		TELEPHONE:	(707) 328-2546
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY:	6	CENSUS: 4	DATE:	03/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:44 PM
MET WITH:	Eufrasia "Oliva" Arizmedi (Licensee)		TIME COMPLETED:	03:41 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	Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Licensee, Eufrasia "Oliva" Arizmedi. Required postings were observed. LPA/Licensee initiated a tour of the facility at 1:00 pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathroom measured at 113.5 and 115.2 degrees F which is within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required grab bars. Kitchen cabinet containing cleaning supplies was locked. Medications were centrally stored and locked. Fire extinguisher charged and serviced as of December 2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have auditory alerts that were functional at time of visit. Last disaster drill was conducted on 12/27/23. Facility has at least two days of perishable and one week of non-perishable foods. File review was initiated at 1:30 pm. Three staff files and four resident files were reviewed. One out of four residents (R1) care plan needs to be updated. Medical assessments were updated for all residents. One out of three staff (S1) do not have required First Aid and CPR certificate updated. All staff have received additional annual training hours required. Administrator's certificate for administrator Eufrasia O Garcia 6049916740 expires 10/15/2024. At approximate 2:00pm LPA/Licensee conducted a spot of medications and their records were reviewed. However, two out of four resident's (R1 & R4) medications were not entered into the Centrally Stored Medication log (CSML). Per Licensee, R4 might leave the facility, so they have not entered their medication into the log yet, but they ensured that R4 had been assisted with their medications. LPA/Licensee discussed the importance and requirement of entering all resident's medication into the CSML accordingly upon resident's admission to the facility. Continue on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TUSCAN MANOR E LLC	FACILITY NUMBER: 496804034
	VISIT DATE: 03/26/2024

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Continued from LIC809...

Licensee to submit updates of the following documents by 4/5/2024: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E) and a copy of Liability Insurance.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Licensee and a copy of this report was given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/26/2024 03:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TUSCAN MANOR E LLC	FACILITY NUMBER: 496804034
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview the licensee did not have at least one staff member who has CPR training on duty at all times. Facility has 1 out of 3 caregivers that work at the facility without a valid CPR certificate which poses a potential health, safety risk to residents in care.
	POC Due Date: 04/05/2024
	Plan of Correction
1 2 3 4	Licensee to ensure that at least one staff on duty has CPR training at all times. Licensee to submit LIC 9098 self certification that staff has been certified for CPR per regulation and that facility will maintain a staff on duty who has CPR training at all times. Self certification to be submitted by POC date of 4/5/24.

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA/staff observation, records review and interview with the licensee, the licensee did not comply with the section cited above in two out of four resident's medications where not entered into the Centrally Stored Medication log accordingly which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/05/2024
	Plan of Correction
1 2 3 4	Facility to submit LIC9098 self-certifying they have conducted staff training on how to properly keep records of medications on CSML to CCL by POC due date to clear the deficiency.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 03/26/2024 03:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TUSCAN MANOR E LLC	FACILITY NUMBER: 496804034
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA/Administrator's file review showing that resident's care plans for 1 out of 4 residents (R1) were not been update and signed by the resident of their representative within last 12 months. This is a potential risk to the health and safety of residents in care.
	POC Due Date: 04/05/2024
	Plan of Correction
1 2 3 4	Administrator agreed to review all resident's care plans, update them accordingly and send self-certification that this process had been done to CCL by POC due date.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC809 (FAS) - (06/04)

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