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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804034
Report Date: 03/11/2022
Date Signed: 03/11/2022 11:12:51 AM

Document Has Been Signed on 03/11/2022 11:12 AM - 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 LLCFACILITY NUMBER:
496804034
ADMINISTRATOR:ARIZMEDI, EUFRASIAFACILITY TYPE:
740
ADDRESS:1920 GROSSE AVETELEPHONE:
(707) 328-2546
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 6DATE:
03/11/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Applicant, Eufrasia ArizmediTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived announced to conduct a Pre-Licensing Inspection and met with Applicant, Eufrasia (Oliva) Garcia Arizmendi.

Upon arrival, LPA was greeted by staff and had their temperature taken and staff instructed LPA to sign in. Applicant has applied for a Change of Ownership at this location so there are already six residents in care. LPA initiated a tour of the facility at approximately 9:05am and made the following observations: Facility is a one story residence with six single resident bedrooms, seven bathrooms and common areas. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Bathroom showers have non-skid shower floors/mats and grab bars. Water temperature in tested bathrooms read at 118 and 119 degrees F which are within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Perishable and non-perishable foods observed per regulation. Facility backyard has multiple areas for visiting and activities. Also on site is a second dwelling that the Applicant identified as a a staff's residence. Staff works the NOC shift. LPA confirmed that staff is awake and is physically in the facility for their shift and does not sleep in their residence at night.

Facility received an approved fire clearance dated November 22, 2021 that allows for five non-ambulatory residents and 1 bedridden resident but does not specify which room or rooms are allowable for bedridden. The provided sketch indicates a shared room but per discussion with Applicant all rooms are single. LPA is requesting an updated sketch to reflect how many residents will be in each room and specify which room will be bedridden. Carbon Monoxide detector was tested and operational. Facility has lighting in hallways. LPA confirmed that contents of the facility First Aid Kit were sufficient and that facility has emergency lighting in case of a power outage.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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
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: 03/11/2022
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Continued from LIC809

Medications and files are secured in a hallway closet and toxins/cleaning supplies are secured in a bathroom closet. LPA and Applicant discussed that all resident files would need to be updated upon Licensure. LPA discussed how to sign up for the Guardian and confirmed that Applicant is signed up for Provider Information Notices (PINs) that the department sends out.

Component III was conducted.

LPA will notify Application Unit regarding noted issues and once remedied, application process may proceed.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC809 (FAS) - (06/04)
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