079200843-10-5-2021-15-AS-DPAO-C7HQBR-20211005120158

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200843
Report Date: 10/05/2021
Date Signed: 10/05/2021 12:03:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	TUSCAN BLUE II		FACILITY NUMBER:	079200843
ADMINISTRATOR:	PRAMOD, KAVITHA		FACILITY TYPE:	740
ADDRESS:	5405 MOJAVE WAY		TELEPHONE:	(510) 331-5774
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 6	DATE:	10/05/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Rony Apostol, House Manager		TIME COMPLETED:	12:10 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	On 10/05/21 at 11AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with house manager (HM). LPA spoke to administrator (ADM) on the phone who authorized HM to act on her behalf and sign the reports. LPA observed 2 staff wearing face masks during visit. LPA observed 5 residents watching TV in the living room while the other resident was observed relaxing in her bedroom. Facility has a mitigation plan in place dated 04/21/21 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with HM as well as COVID-19 infection control practices. LPA inspected the facility inside and outside. One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks and no touch temperature probe. COVID-19 signs are posted throughout the facility to promote handwashing, cough/sneeze etiquette and physical distancing. Facility documents daily temperatures and COVID-19 symptom checks for staff and residents. Pathways were observed to be free of obstruction and fire hazards. A written Emergency/Disaster plan dated 01/01/2019 was posted near a Lan line phone in the kitchen. Centrally stored medications were locked in cabinets near the kitchen area. Sharp objects were locked underneath the kitchen sink. Toxic chemicals were locked in the laundry room and garage. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021

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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TUSCAN BLUE II	FACILITY NUMBER: 079200843
	VISIT DATE: 10/05/2021

NARRATIVE

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Infection control designated leader is the administrator. All staff and residents have been fully vaccinated since February 2021.There was at least 7 days of nonperishable and 2 days of perishable foods. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 74 degrees Fahrenheit. Resident's bedrooms and bathrooms have COVID-19 signages. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational.

Adequate supplies of PPE were also observed stored in the garage. Facility follows daily cleaning, sanitation of frequently touched common surfaces using Clorox and Lysol disinfectants. The facility has auditory signals on each exit door.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 10/06/2021:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan
· Evidence of Liability Insurance

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to HM.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021

LIC809 (FAS) - (06/04)

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