197607906-11-15-2023-11-AS-SLEO-CXLTCT-20231115133716

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607906
Report Date: 11/15/2023
Date Signed: 11/15/2023 01:37:29 PM

Document Has Been Signed on 11/15/2023 01:37 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	TWIN HOMECARE - A		FACILITY NUMBER:	197607906
ADMINISTRATOR:	NAPOLEON GARCIA		FACILITY TYPE:	740
ADDRESS:	2104 W. 242ND STREET		TELEPHONE:	(424) 263-4779
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY:	6	CENSUS: 4	DATE:	11/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Charesa Reyes - Administrator		TIME COMPLETED:	01:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/15/2023 at around 9:15 AM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Administrator Charesa Reyes. LPA explained the purpose of the visit and was accompanied by a Caregiver inside and outside the facility during this inspection. This facility is licensed to serve 6 non-ambulatory residents, of which 6 may be bedridden, and 6 residents may be in hospice care. A total of 4 ambulatory residents are currently residing in this facility. 2 are ambulatory residents and 2 are non-ambulatory residents. The Annual Licensing Fees are current. The home consists of 6 resident bedrooms, 3 resident bathrooms, 1 staff bedroom, 1 staff bathroom, 1 living room, 1 entrance/dining room, 1 kitchen, 3 car garage, 1 laundry room, 1 linen room, and 1 backyard patio area with shaded seating. Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in a locked storage cabinet.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TWIN HOMECARE - A	FACILITY NUMBER: 197607906
	VISIT DATE: 11/15/2023

NARRATIVE

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LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last fire and earthquake drill was conducted on 10/30/2023. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. A new fire extinguisher was observed near the kitchen area.

6 out of 6 resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature in resident bathroom sinks, and it measured between 138 to 143.4 Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, non-medicated soap, toilet paper, toothbrush, toothpaste, and comb.

4 resident records were reviewed and, 4 out of 4 resident records had Admission Agreements, Medical Assessments, Consent Forms, Weight Record, Emergency Information, Appraisal & Needs Service Plan, Tuberculosis Test, Centrally Stored Medication Destruction Record, and Personal Rights.

4 staff records were reviewed, 4 out of 4 staff records had current First Aid Certificates, Criminal Record Clearances, Job Applications, Tuberculosis Test, Facility Training/Drills, and signed Employee Rights.

Deficiencies are being cited based on LPA observation in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding hot water temperature measuring above 120 Fahrenheit.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2023 01:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TWIN HOMECARE - A	FACILITY NUMBER: 197607906
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2023
	Plan of Correction
1 2 3 4	Licensee will fix hot water temperature and will email proof of correction to Socorro.Leandro@dss.ca.gov. Licensee will email video recording of residents bathroom sink and shower mesuring between 105 to 120 degree F.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC809 (FAS) - (06/04)

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