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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600878
Report Date: 02/13/2025
Date Signed: 02/13/2025 02:44:56 PM

Document Has Been Signed on 02/13/2025 02:44 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:TWIN CARE HOME INCFACILITY NUMBER:
198600878
ADMINISTRATOR/
DIRECTOR:		MARIE EDNA GARBANZOSFACILITY TYPE:
735
ADDRESS:419 W RENWICK ROADTELEPHONE:
(626) 963-1562
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 4CENSUS: 2DATE:
02/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Assistant Administrator Kevin GarbanzosTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Assistant Administrator Kevin Garbanzos at approximately 12:00 PM and explained reason for visit.

The facility is licensed to serve 4 non-ambulatory developmentally disabled clients aged 18 to 59. Currently, there are two (2) clients in placement. All clients residing at this facility receive case management services provided by San Gabriel/Pomona Regional Center. The facility is in a residential area, and it is a one-story family home. A tour of the single-story facility included the living room, family room, kitchen, 3 client bedrooms,1 staff room, 2 bathrooms, laundry area, front yard, backyard, shed, and detached garage.



LPA toured the facility and observed the following: One shared client bedroom has the required furniture and bedding. There is extra clean linen and towels in bedroom closet. Smoke detectors/carbon monoxide detectors were observed in each room and throughout facility. The facility has one (1) fire extinguisher which is kept in laundry area and has not been inspected deficiency cited. Cleaning supplies and toxic substances are inaccessible locked in cupboards in laundry area. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or large body of water. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction.

SEE LIC 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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 4
Document Has Been Signed on 02/13/2025 02:44 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 02/13/2025 at 02:19 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: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above LPA observed fire extinguisher has not been inspected and no proof of purchase could be provided which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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Assistant Administrator agreed to provide receipt of when fire extinguisher was purchased and keep receipt to show purchase date for future inspections. Will be emailed to LPA by POC due date.
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in one (1) out of four (4) staff did not have a current CPR/First Aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2025
Plan of Correction
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Assistant Administrator will email LPA S4 current CPR/First Aid card by POC due date.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/13/2025 02:44 PM - It Cannot Be Edited


Created By: Christian Gutierrez On 02/13/2025 at 02:19 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: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

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 last drill was conducted in August of 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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Assistant Administrator will conduct drill and send a copy to LPA by POC due date.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TWIN CARE HOME INC
FACILITY NUMBER: 198600878
VISIT DATE: 02/13/2025
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Three (3) out of four (4) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. S4 CPR/First Aid was expired. Two (2) client files were reviewed and included physicians report, TB clearance, and individual program plan (IPP)report. Last fire/earthquake drill was conducted in August of 2024. Infectious control plan was reviewed. One (1) staff was interviewed. Two (2) clients interviewed were attempted both clients non-verbal. Two (2) client medications were reviewed. Medications are centrally stored and locked MAR log is used.

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



An exit interview was held with Kevin Garbanzos and a copy of the report and appeal rights were provided.



SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4