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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600878
Report Date: 02/24/2023
Date Signed: 02/24/2023 04:34:26 PM

Document Has Been Signed on 02/24/2023 04:34 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:TWIN CARE HOME INCFACILITY NUMBER:
198600878
ADMINISTRATOR:MARIE EDNA GARBANZOSFACILITY TYPE:
735
ADDRESS:419 W RENWICK ROADTELEPHONE:
(626) 963-1562
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 4CENSUS: 2DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Edna Garbanzos- AdminstratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) V. Maldonado conducted an unannounced visit to the facility for the purpose of conducting the require annual inspection using the infection control tool to evaluate the facility. LPA met with Administrator Edna Garbanzos Assistant Administrator Kevin Garbanzos and explained the purpose for the visit. LPA conducted a tour of the physical plant, observed COVID-19 procedures, reviewed clients' medications and records, observed food supply, and reviewed staff records. The facility cares for developmentally disabled adults and currently has 2 clients in care.

The facility is a residential home that consists of (4) bedrooms, (2) bathrooms, a living room, dining room, kitchen, storage shed, detached garage, and a shaded patio in the backyard with seating. (3) of (4) bedrooms are client bedrooms. Client bedrooms were toured and each had the required furniture and sufficient closet and storage space. The bathrooms have the required grabs bars and non-skid mat. LPA observed cleaning supplies left out in a shower caddy inside bathroom# 1. Kevin stated they just finished cleaning and immediately put the supplies away in the closet and locked it. The hot water was tested and measure at 120*F, which is within the required temperature, per Title 22 Regulations. Toxins/Cleaning supplies are stored in a cabinet above the washing machine, locked and inaccessible to clients. The food supplies was observed and facility had the required 2-day perishables and 7-day non-perishable food. While touring the kitchen, LPA observed a knife and a pair of cooking scissors in the kitchen sink. Kevin stated staff just washed the items and were left to dry, but immediately took them and stored them in a drawer next to the refrigerator. The sharps are locked in that drawer and made inaccessible to clients. LPA also observed several gas lighters and a can of butane fuel next to the microwave in the kitchen and accessible. Kevin apologized for leaving them out and stored them to make them inaccessible right away.



(Report Continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TWIN CARE HOME INC
FACILITY NUMBER: 198600878
VISIT DATE: 02/24/2023
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There is a screening station at the entrance of the home, however staff failed to screen LPA upon entry and observed staff not wearing face masks. LPA prompted staff to put on face masks. A 30-day supplies of Personal Protective Equipment (PPE) was observed in a closet inside the home and in the garage. Additional PPE was observed at the entrance of the home at the screening station, readily available for client/staff/visitor use. COVID-19 signange was observed at the entrance and throughout the facility to promote mask wearing, social distancing, hand washing, and cough/sneeze etiquette. Technical Advisories will be issued due to facility failing to follow all COVID-19 guidance, per the licensing agency.

LPA reviewed (2) client files for updated emergency contact information and current health screenings- confirmed to be on file. LPA reviewed (3) staff files for health screenings, proof of required annual training, and fingerprint clearances- confirmed to be on file. LPA reviewed (2) clients' medications and were observed to be documented properly and given as prescribed.

Per California Code of Regulations, Title 22, deficiencies were observed and are cited on the LIC809-D.

An exit interview was held with Edna Garbanzos and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/24/2023 04:34 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 02/24/2023 at 02:37 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TWIN CARE HOME INC
FACILITY NUMBER: 198600878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in a kitchen knife, a pair of kitchen scissors, 2 bottles of cleaning solution, butane fuel, and gas lighters- all left out and accessible, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2023
Plan of Correction
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Assistant Administrator took all items and removed them immediately to store them properly and make them inaccessible to persons in care. This deficiency was corrected.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


LIC809 (FAS) - (06/04)
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