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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804034
Report Date: 05/26/2022
Date Signed: 05/26/2022 01:41:42 PM

Document Has Been Signed on 05/26/2022 01:41 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, 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 AVENUETELEPHONE:
(707) 328-2546
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 6DATE:
05/26/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Licensee, Eufrasia (Oliva) Garcia ArizmendiTIME COMPLETED:
01:51 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct a Post Licensing inspection and met with Licensee, Eufrasia (Oliva) Garcia Arizmendi.. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed posters outside notifying visitors that masks must be worn in the facility and what the facility's visitation policy is. Once inside, LPA observed a screening station near the entrance that included a visitor sign in. Licensee checked LPA temperature and LPA confirmed that facility is screening visitors and verifying visitor vaccination per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility around 12:40 pm and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected on each shift. Facility maintains documentation of staff and resident daily temperatures.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff have completed PPE training but have not been N95 fit tested. LPA discussed options for getting staff fit tested with Licensee. LPA and Licensee discussed visitation and activities. Facility has at least a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication.

Licensee and LPA discussed their Emergency Disaster Plan and the Infection Control Plan. The Infection Control Plan is due June 30, 2022. LPA confirmed that Licensee is updating resident files for residents who lived in the home prior to the recent Change of Ownership.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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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