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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881142
Report Date: 05/21/2025
Date Signed: 05/21/2025 11:07:16 AM

Document Has Been Signed on 05/21/2025 11:07 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TWIN HEARTS SENIOR CARE, LLCFACILITY NUMBER:
331881142
ADMINISTRATOR/
DIRECTOR:		MANGENTE, KRISTINE A.FACILITY TYPE:
740
ADDRESS:995 BOUQUET CIR.TELEPHONE:
(951) 736-6925
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 6CENSUS: DATE:
05/21/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Licensee Kristine Mangente TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico and Licensing Program Analyst Manager (LPM) Efren Malagon met with Licensee Kristine A. Mangente at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to provide a case management report pertaining to complaint 56-AS-20250114090200.

On 1/15/2025, during visit, LPA Rico requested R1 file for review. For the following documents: Physician Report, Admission Agreement, Preplacement Appraisal and Hospice Care Plan. S1 stated the only document available for R1 was the Admission Agreement, which was observed to be incomplete. Prior to R1 move-in, the following documents should’ve been completed and kept for a minimum of three years.

Furthermore, LPA request a copy of R1 Death Report. S1 stated that they did not have copy and did not submit a death report to Community Care Licensing. LPA verity R1 Death Report was not submitted to Community Care Licensing database.

A total of six (6) deficiencies was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report, LIC809, LIC809D, were discussed and provided to Licensee Kristine A. Mangente. Along with a copy of appeal rights.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Mary Rico
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/21/2025 11:07 AM - It Cannot Be Edited


Created By: Mary Rico On 05/21/2025 at 08:43 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC
FACILITY NUMBER: 331881142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2025
Section Cited
CCR
87211(a)(1)

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87211(a) (1)Reporting Requirements A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This requirement is not met as evidenced by:
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The licensee has agreed to read regulation entirely and send LPA a self-certified letter that the regulation was read and understood.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not submitting R1 death report to CCL which poses/posed a potential health, safety or personal rights risk to persons in care.
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POC due date 5/28/2025.
Type B
05/28/2025
Section Cited
CCR87633(a)(4)

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87633(a)(4) Hospice Care of Terminally Ill Residents4)A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision.. This requirement is not met as evidenced by:
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The licensee has agreed to read regulation entirely and send LPA a self-certified letter that the regulation was read and understood.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having R1's Hospice File which poses/posed a potential health, safety or personal rights risk to persons in care.
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POC due date 5/28/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/21/2025 11:07 AM - It Cannot Be Edited


Created By: Mary Rico On 05/21/2025 at 08:50 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC
FACILITY NUMBER: 331881142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2025
Section Cited
CCR
87597(c)

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87507(c) Admission Agreements
(c) Admission agreements shall be signed and dated,.. the contents of the document, .. resident’s representative, if any,.. designated representative no later than seven days following admission. This requirement is not met as evidenced by:
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The licensee has agreed to read regulation entirely and send LPA a self-certified letter that the regulation was read and understood.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by having an incomplete Admission Agreement for R1which poses/posed a potential health, safety or personal rights risk to persons in care.
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POC due date 5/28/2025
Type B
05/28/2025
Section Cited
CCR87457(c)

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87457 ( c ) Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission
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The licensee has agreed to read regulation entirely and send LPA a self-certified letter that the regulation was read and understood.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having R1 Pre-admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
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POC due date 5/28/2025
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/21/2025 11:07 AM - It Cannot Be Edited


Created By: Mary Rico On 05/21/2025 at 08:59 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC
FACILITY NUMBER: 331881142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2025
Section Cited
CCR
87458(a)

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87458 (c) Medical Assessment 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. This requirement is not met as evidenced by:
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The licensee has agreed to read regulation entirely and send LPA a self-certified letter that the regulation was read and understood
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a copy of R1 medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
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POC due date 5/28/2025
Type B
05/28/2025
Section Cited
CCR87506(e)

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87506(e) Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by:
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The licensee has agreed to read regulation entirely and send LPA a self-certified letter that the regulation was read and understood
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Based on observation, interview and record review, the licensee did not comply with the section cited above by keeping R1 records for a minimum of three years which poses/posed a potential health, safety or personal rights risk to persons in care.
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POC due date 5/28/2025
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2025


LIC809 (FAS) - (06/04)
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