<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201002
Report Date: 11/22/2022
Date Signed: 11/22/2022 12:59:52 PM

Document Has Been Signed on 11/22/2022 12:59 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:TUSCANY VILLA SENIOR LIVINGFACILITY NUMBER:
019201002
ADMINISTRATOR:GOMBIO, JANICEFACILITY TYPE:
740
ADDRESS:790 HOLMES STREETTELEPHONE:
(925) 371-3090
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 31CENSUS: 19DATE:
11/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Janice Gombio, AdministratorTIME COMPLETED:
01:15 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 11/22/2022 at 10:58AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management inspection in regards to incident report received on 11/19/2022. LPA met with Administrator, Janice Gombio.

Incident report dated 11/19/2022 revealed that R1 AWOL without setting off door alarms. Law enforcement contacted facility that R1 was found and R1 returned to the facility a couple hours later.

Interview with staff revealed that R1 left the facility and staff didn't hear the door alarms. R1 might have left the facility near the exit door by R1's room. Staff stated the exit door might have been open at that time.

During record review, LPA observed that physician's report dated 3/17/2021 stated that R1 cannot leave the facility unassisted.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalty.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/22/2022 12:59 PM - It Cannot Be Edited


Created By: Grace Luk On 11/22/2022 at 12:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TUSCANY VILLA SENIOR LIVING
FACILITY NUMBER: 019201002

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2022
Section Cited
CCR
87705(j)

1
2
3
4
5
6
7
Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator has agreed to create a written plan to address alarm exit doors to prevent future AWOLs. Administrator will submit written plan to CCLD by POC date.
8
9
10
11
12
13
14
Based on interview, licensee did not comply with the section cited above by having unalarmed exit door which poses an immediate health and safety risk to the persons in care.
8
9
10
11
12
13
14
Type B
11/30/2022
Section Cited
CCR87705(c)(5)

1
2
3
4
5
6
7
Care of Persons with Dementia. Each resident with dementia shall have an annual medical assessment...at least annually...
This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator has agreed to obtain a current medical assessment for R1 and submit a copy to CCLD by POC date.
8
9
10
11
12
13
14
Based on record review, licensee did not comply with the section cited above by not having a current medical assessment for R1 which poses a potential health and safety risk to the persons in care.
8
9
10
11
12
13
14
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2