079200843-1-23-2026-15-AS-BFOG-DR5SRL-20260209130632

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200843
Report Date: 01/23/2026
Date Signed: 01/23/2026 05:33:00 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/03/2025 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20251203084650

FACILITY NAME:	TUSCAN BLUE II		FACILITY NUMBER:	079200843
ADMINISTRATOR:	PRAMOD, BALANANDAN		FACILITY TYPE:	740
ADDRESS:	5405 MOJAVE WAY		TELEPHONE:	(510) 331-5774
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 6	DATE:	01/23/2026
		UNANNOUNCED	TIME BEGAN:	05:08 PM
MET WITH:	Kavitha Pramod, Administrator Rony Apostol, Staff		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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Staff failed to provide necessary hydration, nutrition and basic care
Administrator and staff failed to monitor and supervise the resident
Staff failed to ensure the resident received necessary medical supplies and monitoring

INVESTIGATION FINDINGS:

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On 01/23/26 5PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with staff (S1) and spoke to administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA delivered investigation findings to ADM and S1. LPA explained the purpose of the visit with staff.

During investigation, LPA obtained the following documents from administrator – Personnel record (LIC500), Resident roster, pre-appraisal reports, Admission agreements, physician's reports, Needs/Services plans, ID/Emergency information, Hospice care plans, Medication administration records (MARs starting July 2025 to December 2025), special diet records, Care Progress notes, incident reports.

Continued on next page, LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20251203084650

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/23/2026

NARRATIVE

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Allegation: Staff failed to provide necessary hydration, nutrition and basic care
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed reporting party (RP), staff (ADM, S1) and reviewed R1’s documents. Resident (R1) had a fall from her home and was first admitted at the facility on 07/19/25. During her stay at the facility, R1 was evaluated by her primary care physician who recommended hospice services be provided since R1 would not eat because she did not like the taste of medications given. R1 was admitted into hospice care on 08/26/25. Staff (ADM, S1) stated they followed the hospice care plan for R1 which was to provide a special diet (R1 has Type 2 diabetes), hydrate and continue to administer medications, document refusal of medications and work with hospice care team in assisting R1 improve her condition. On 11/21/25, hospice care team determined R1's health has improved to the point that hospice care is no longer required. Review of R1’s hospice discharge summary report dated 11/22/25 showed R1 had improved mid-arm circumference. Hospice discharge report also showed R1’s initial intake of meals were 30%, upon discharge her daily consumption of meals were 25 to 75%, eating 3 meals a day. occasionally eating 100%. Her independent functioning has improved from 1: 1 feeding on admission to being able to feed herself on discharge and that R1 had a stage 2 pressure injury on admission but was healed at the time of discharge. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff failed to provide necessary hydration, nutrition and basic care to R1 is unsubstantiated.

Continued on next page, LIC9099-C pg2

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20251203084650

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/23/2026

NARRATIVE

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Allegation: Administrator and staff failed to monitor and supervise the resident
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed reporting party (RP), staff (ADM, S1) and reviewed R1’s documents. Review of R1’s physician’s and appraisal reports dated 07/19/25 and 09/08/25 showed R1 health history as acute failure to thrive, protein calorie malnutrition and dementia. On 08/26/25, R1 was admitted into hospice care. On 11/21/25, the hospice care team determined R1’s health improved and released her from hospice care. However, due to R1’s continued refusal to eat because she did not like the taste of medications given, ADM stated both R1’s authorized representative (DPOA) and primary care physician (PCP) decided to put her back into hospice care on 12/30/25 due to her declining health condition. Staff (ADM, S1) stated they continue to monitor/ supervise R1 and follow the hospice care plan for R1 which was to provide special diet (R1 has Type 2 diabetes), hydrate and continue to administer medications, document refusal of medications and work with hospice care team in assisting R1 improve her condition. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff failed to monitor and supervise the resident is unsubstantiated.

Allegation: Staff failed to ensure the resident received necessary medical supplies and monitoring
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed reporting party (RP), staff (ADM, S1) and reviewed R1’s documents. On 12/03/25. LPA observed R1 to be clean, well groomed, odor free and comfortable with staff assisting with her activities of daily living (ADLs – incontinent care, meals, medication administration, grooming, dressing, bathing, toileting). LPA toured the facility and observed R1 had an approved medical bed, a wheelchair, side table and sufficient supply of diapers and medications as prescribed by her primary care physician (PCP). Staff (ADM, S1) stated they followed R1’s hospice care plan and continue to administer medications, document refusal of medications and work with hospice care team in assisting R1 improve her health condition. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff failed to ensure the resident received necessary medical supplies and monitoring is unsubstantiated.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/03/2025 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20251203084650

FACILITY NAME:	TUSCAN BLUE II		FACILITY NUMBER:	079200843
ADMINISTRATOR:	PRAMOD, BALANANDAN		FACILITY TYPE:	740
ADDRESS:	5405 MOJAVE WAY		TELEPHONE:	(510) 331-5774
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 6	DATE:	01/23/2026
		UNANNOUNCED	TIME BEGAN:	05:08 PM
MET WITH:	Kavitha Pramod, Administrator Rony Apostol, Staff		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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The facility misrepresented itself as a hospice provider

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20251203084650

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/23/2026

NARRATIVE

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Allegation: The facility misrepresented itself as a hospice provider
Investigation Finding: Unfounded
During investigation LPA interviewed reporting party (RP), staff (ADM, S1) and reviewed R1’s documents. Review of the State License issued on 10/04/2019 to the facility as a Residential Care Home for the Elderly (RCFE) showed the facility has an approved hospice waiver for three (3) residents. The facility is permitted to accept or retain residents who have been diagnosed as terminally ill by his or her primary care physician to reside in the facility and receive hospice services from a hospice agency in the facility. This Department has investigated the allegation that the facility misrepresented itself as a hospice provider and found the allegation without a reasonable basis and is therefore unfounded.

No deficiency cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

LIC9099 (FAS) - (06/04)

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