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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804034
Report Date: 02/06/2025
Date Signed: 02/06/2025 03:39:26 PM

Document Has Been Signed on 02/06/2025 03:39 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:TUSCAN MANOR E LLCFACILITY NUMBER:
496804034
ADMINISTRATOR/
DIRECTOR:		ARIZMEDI, EUFRASIAFACILITY TYPE:
740
ADDRESS:1920 GROSSE AVENUETELEPHONE:
(707) 328-2546
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 6DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Eufrasia Garcia, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
NARRATIVE
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At approximately 8:00 AM Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct an Annual Required Inspection and was greeted by a Caregiver. Administrator, Eufrasia "Oliva" Garcia arrived at 8:30 AM. Facility is a single story ranch house. Facility has an approved fire clearance for six (6) non-ambulatory residents with an approved Hospice waiver for three (3). Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Upon arrival, LPA was informed that there were six (6) clients in care and two (2) staff members on-site. At approximately 8:30 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 8:45 AM, LPA toured the facility with Administrator Garcia. All exits were clear and unobstructed. Fire extinguisher was last serviced and tagged on 12/5/2024. Food supply was sufficient. The facility was sufficiently lighted and Furnished. During the inspection, LPA observed that there was no Residential Care Facility for the Elderly (RCFE) complaint poster (PUB 475) posted in a conspicuous location as per Title 22 Regulations. A Technical Violation is being issued for the PUB 475 not being posted. LPA inspected three (3) client bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Toxins were observed to be stored inaccessible to clients. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The last disaster drill was conducted on 12/1/2024. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for four (4) sinks in facility were measured and three (3) of four (4) were observed to exceed Title 22 regulations of 105 to 120 degrees Fahrenheit. This deficiency will be cited. Facility smoke detectors and carbon monoxide detectors were tested and operational.

Continued on 809...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TUSCAN MANOR E LLC
FACILITY NUMBER: 496804034
VISIT DATE: 02/06/2025
NARRATIVE
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...Continued from 809

At approximately 10:15 AM, LPA reviewed six (6) staff files. LPA observed that one (1) staff member (S1) did not have an LIC 503 Health Screening Report - Facility Personnel on File. In Addition, one (1) staff member (S2) did not have their LIC 503 signed by an authorized health care professional. These deficiencies will be cited. All staff members had current First Aid and CPR certification and proper training documentation. LPA reviewed five (5) resident files. LPA observed that one (1) resident's (R1) file did not have a 602A Physician's Report for Residential Care Facilities for the Elderly (RCFE). This deficiency will be cited. Four (4) residents' files were observed to have all required documentation. LPA spot checked Medication for three (3) residents. LPA observed that three (3) of three (3) residents medications were not properly documented in the LIC 622 Centrally Stored Medication and Destruction Records per Title 22 Regulations. These deficiencies will be cited. The facility does not handle client monies for personal and incidental items.

Administrator's Certificate renewal for Eufrasia Garcia (7017395740) was received by Community Care Licensing on 10/3/2024.

LPA requested the following documents be submitted to Community Care Licensing by 3/6/2025:

LIC 308 Designation of Responsibility
LIC 610D Emergency Disaster Plan
Proof of Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted. Copy of report, LIC809Ds (Deficiency Pages) with plans of corrections, LIC9102 Technical Violation, Confidential Names (LIC811), and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 02/06/2025 03:39 PM - It Cannot Be Edited


Created By: Robert Frank On 02/06/2025 at 02:15 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TUSCAN MANOR E LLC
FACILITY NUMBER: 496804034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in three (3) out of four (4) water temperatures tested exceeded 120 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Licensee/Administrator to ensure the hot water is within regulation at all times-no lower than 105F and no higher than 120F. Administrator will turn down the hot water heater and will continue to monitor the hot water to bring it within regulation. Administrator will log the hot water for a period of one week ensuring compliance with hot water range regulation. Administrator will submit copy of the hot water log for the first four (4) days to CCL on 2/10/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Robert Frank
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/06/2025 03:39 PM - It Cannot Be Edited


Created By: Robert Frank On 02/06/2025 at 02:15 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TUSCAN MANOR E LLC
FACILITY NUMBER: 496804034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above that one (1) staff member (S1) did not have an LIC 503 Health Screening Report - Facility Personnel on File. In Addition, one (1) staff member (S2) did not have their LIC 503 signed by an authorized health care professional.
POC Due Date: 02/13/2025
Plan of Correction
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Administrator will submit to Community Care Licensing completed LIC 503 Health Screening Report - Facility Personnel reports by POC Due Date. Administrator will also self certify that all staff member files have been reviewed for required documentation by POC Due Date of 2/13/2025.

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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Robert Frank
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 02/06/2025 03:39 PM - It Cannot Be Edited


Created By: Robert Frank On 02/06/2025 at 02:15 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TUSCAN MANOR E LLC
FACILITY NUMBER: 496804034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that one (1) of five (5) resident’s files (R1) did not have a 602A Physician's Report for Residential Care Facilities for the Elderly (RCFE), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Administrator will submit to Community Care Licensing a completed 602A Physician's Report for Residential Care Facilities for the Elderly (RCFE) for resident 1 (R1) by POC due date of 3/6/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Robert Frank
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 02/06/2025 03:39 PM - It Cannot Be Edited


Created By: Robert Frank On 02/06/2025 at 02:57 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TUSCAN MANOR E LLC
FACILITY NUMBER: 496804034

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
87465(h)(6)(E)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
(E) The prescription number and the name of the issuing pharmacy.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in three (3) residents had errors on their Centrally Stored Medication and Destruction Records. Four (4) errors for resident two (R2). Two errors for Resident three (R3), and 1 error for Resident four (R4) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Administrator will Audit all Centrally Stored Medication and Destruction records for all residents and Submit them to Community Care Licensing by POC Due Date of 2/10/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Robert Frank
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
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