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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201002
Report Date: 02/20/2025
Date Signed: 02/20/2025 06:20:37 PM

Document Has Been Signed on 02/20/2025 06:20 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/
DIRECTOR:		GOMBIO, JANICEFACILITY TYPE:
740
ADDRESS:790 HOLMES STREETTELEPHONE:
(925) 371-3090
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 31CENSUS: 25DATE:
02/20/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:Janice Gombio, Executive Director
Isabel Poderoso, Campus Director		TIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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On 2/20/2025 at 4:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to an incident report. LPA met with Executive Director (ED), Janice Gombio and Campus Director, Isabel Poderoso. While LPA was at the facility for another visit, ED provided LPA a copy of a recent incident report.

Based on the incident report dated 2/20/2025, at around 1:35PM on 2/19/2025 staff went to the front lobby and noted the front door was propped open. Staff immediately searched the area and conducted a head count of residents. It was noted that two residents (R1 and R2) were not in the building. Staff searched for residents and called 911. R1 and R2 was found by staff and police at a nearby grocery store. R1 and R2 returned back to the facility with staff.

During visit, LPA interviewed staff and reviewed R1 and R2's file including physician's report and incident report. R1 and R2's physician's report stated that R1 and R2 cannot leave the facility unassisted. Interview with staff revealed that the front door delayed egress door was propped open and there was no staff at the front desk during that time.

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

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: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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Document Has Been Signed on 02/20/2025 06:20 PM - It Cannot Be Edited


Created By: Grace Luk On 02/20/2025 at 05:55 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: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2025
Section Cited
CCR
87468.2(a)(4)

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Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency...
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Executive Director (ED) has agreed to conduct in-service training regarding front door not being propped open. ED will submit staff sign-in sheet and materials to CCLD by POC date.
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This requirement is not met as evidence by: Based on interviews and record review, the licensee did not comply with the section cited above by having two residents leaving the facility unassisted which poses a potential health and safety risk to the persons in care.
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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: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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