331881142-8-27-2024-56-AS-MBRN-D8K3RA-20240827182824

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881142
Report Date: 08/27/2024
Date Signed: 08/27/2024 06:29:43 PM

Document Has Been Signed on 08/27/2024 06:29 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	TWIN HEARTS SENIOR CARE, LLC		FACILITY NUMBER:	331881142
ADMINISTRATOR:	MANGENTE, KRISTINE A.		FACILITY TYPE:	740
ADDRESS:	995 BOUQUET CIR.		TELEPHONE:	(951) 736-6925
CITY:	CORONA	STATE: CA	ZIP CODE:	92881
CAPACITY:	6	CENSUS: 4	DATE:	08/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator Susan Nuguid		TIME COMPLETED:	06:30 PM

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On 08/27/2024 at 12:00 PM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with Staff #2 (S2) and was granted entry to the facility. At the time of the visit there were three (3) staff present, and four (4) residents present. Administrator Susan Nuguid was contacted and informed of the visit. Administrator Nuguid arrived during the visit. LPA Brown explained the purpose of the visit to Administrator Nuguid.

The facility is a four (4) bedroom, two (2) bathroom home with a kitchen/dining area, living room, activity room and laundry area. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be ambulatory and four (4) may be non-ambulatory, and one (1) bedridden resident. The facility has six (6) Hospice Waiver. The current census is four (4) residents. LPA Brown was accompanied by Staff #2 (S2) to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor but observed obstructions to outdoor passageways. Deficiency will be issued. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. LPA Brown observed sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms. However, LPA Brown observed no night lights maintained in hallways and passages to nonprivate bathrooms. Deficiency will be issued. Also, LPA Brown observed screen door in disrepair. Technical Violation issued.

***Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

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 59

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 331881142
	VISIT DATE: 08/27/2024

NARRATIVE

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Also, LPA Brown observed Resident #1 (R1) with full bed rail and Administrator Nuguid reported to LPA Brown that R1 is not on Hospice Care and no written order from R1 physician was observed indicating the need for postural support/full bed rail. LPA Brown observed no exception letter submitted and approved by Community Care Licensing Division (CCLD) for R1's full bed rails. Deficiency will be issued. To add to that, LPA Brown observed Resident #3 (R3) has half bed rails. Administrator Nuguid reported to LPA Brown that R3 does have written order from R3 physician indicating the need for half bed rail for mobility. Deficiency will be issued. Moreover, during the tour of the facility, LPA Brown observed three (3) bottles of chemicals in the backyard, not locked and accessible to residents in care. Deficiency will be issued. Per records review, the facility was cited for the same deficiency within 12-month period. A civil penalty of $250.00 will be assessed today and will continue to be assessed of $100.00 per day if not corrected. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 96 degrees Fahrenheit. Deficiency will be issued. The facility is equipped with operating smoke detectors but no carbon monoxide alarms. Deficiency will be issued. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area. Furthermore, there was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked. Also, LPA Brown observed incomplete First Aid Kit and no current edition of first aid manual approved by the American Red Cross, The American Medical Association or a state or federal health agency maintained at the facility. Deficiency will be issued.

Food Service: Seven (7) days non-perishable food supply and two (2) days perishable food supply observed at the facility.

Care & Supervision: The facility has an administrator present in the facility. LPA Brown observed sufficient number of staff to provide care and supervision to the residents in care and there's a staff scheduled to work the night shift as required for facility with dementia residents.

Record Review: LPA reviewed two (2) resident files for admission agreements, updated physician reports, and Pre-placement Appraisals. LPA Brown observed no Pre-placement Appraisal completed for Resident #2 (R2) and Resident #3 (R3). Deficiency will be issued. Also, LPA Brown observed Resident #4 (R4) does not have the required annual or updated medical assessment for dementia residents. Deficiency will be issued.

***Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

Page: 59 of 59

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 331881142
	VISIT DATE: 08/27/2024

NARRATIVE

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LPA reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown observed Staff #2 (S2) and Staff #3 (S3) without Health Screening Report maintained in S2 and S3 facility file. Deficiency will be issued. LPA Brown observed Staff #2 (S2) and Staff #3 (S3) did not complete the required Tuberculosis (TB) Test. Deficiency will be issued. LPA Brown observed Staff #2 (S2) and Staff #3 (S3) were not provided the required on the job training. Deficiency will be issued. LPA Brown observed Staff #2 (S2) and Staff #3 (S3) did not complete the required training prior to providing services to the residents. Deficiency will be issued. LPA Brown observed no completed Dementia Care Training for Staff #2 (S2) and Staff #3 (S3). Deficiency will be issued. LPA Brown observed Staff #3 (S3) did not complete the required First Aid from persons qualified by such agencies as Red Cross. Deficiency will be issued. LPA Brown observed Staff #2 (S2) and Staff #3 (S3) did not complete the required 10 Hours Medication Training. Deficiency will be issued. Also, LPA Brown was informed that Staff #4 (S4) worked at the facility for two (2) days and per records review, LPA Brown observed S4 with criminal background clearance but S4 clearance was not transferred to the facility prior to employment. Deficency will be issued and civil penalty of $200.00 will be assessed as Administrator Nuguid reported to LPA Brown that S4 worked two (2) days at the facility and will continue to be assessed of $100.00 per day until corrected.

Lastly, during medication audit, LPA Brown observed Resident #1 (R1) two (2) medications were not given according to R1's physician's directions. Deficiency will be issued. Also, no Liability Insurance observed at the facility as Licensee only submitting/showing document with effective date of the policy but no end date. To add to that, Licensee submitted insurance finance agreement and insurance quote and not the Actual policy to LPA Brown that will show start date and end date of policy. Deficiency will be issued.

An exit interview was conducted where this report (LIC809), LIC809D, LIC9102, LIC421FC, LIC421BG and Appeal Rights were discussed and provided to Administrator Susan Nuguid.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

Page: 2 of 59

Document Has Been Signed on 08/27/2024 06:29 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 331881142
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's a carbon monoxide detector maintained at the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2024
	Plan of Correction
1 2 3 4	Licensee stated to obtain/purchase carbon monoxide detector and submit proof to LPA Brown on Plan of Correction (POC) due date.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the three bottles of chemicals observed in the backyard were locked and not accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2024
	Plan of Correction
1 2 3 4	Licensee immediately locked the three (3) bottles of chemicals during the visit. Also, Licensee stated to train all staff on CCR 87309(a) and submit proof of staff training log to LPA Brown on 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

Page: 3 of 59

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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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 331881142
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87412(a)(11)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above y not ensuring that Staff #2 (S2) and Staff #3 (S3) complete the required Health Screening Report which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit S2 and S3 medical appointment to complete the required Health Screening Report to LPA Brown on Plan of Correction (POC) due date.

Type A

Section Cited

CCR

87412(a)(12)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #2 (S2) and Staff #3 (S3) complete the required Tuberculosis (TB) test which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2024
	Plan of Correction
1 2 3 4	LIcensee stated to submit S2 and S3 medical appointment to complete the required TB Test to LPA Brown on 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

Page: 4 of 59

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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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 331881142
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(d)

Personnel Requirements - General

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not providing the required on the job training fro Staff #2 (S2) and Staff #3 (S3) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2024
	Plan of Correction
1 2 3 4	Licensee stated to provide the required on the job training for S2 and S3 and submit proof to LPA Brown on Plan of Correction (POC) due date.

Type A

Section Cited

HSC

1569.625(c)(7)

Other Provisions

(c) The training shall include, but not be limited to, all of the following: (7) Dementia care, including the use and misuse of antipsychotics, the interaction of drugs commonly used by the elderly, and the adverse effects of psychotropic drugs for use in controlling the behavior of persons with dementia. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not providing the required dementia care training to Staff #2 (S2) and Staff #3 (S3) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2024
	Plan of Correction
1 2 3 4	Licensee stated to provide the required dementia training to S2 and S3 or proof of enrollment to Demential Training for S2 and S3 and submit proof to LPA Brown on 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

Page: 5 of 59

Document Has Been Signed on 08/27/2024 06:29 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 331881142
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) complete the required First Aid Training from persons qualified by such agencies as the American Red Cross which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit S3 proof of enrollment to complete the required First Aid Training or certificate of completed First Aid Training to LPA Brown on Plan of Correction (POC) due date.

Type A

Section Cited

HSC

1569.69(a)(2)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #2 (S2) and Staff #3 (S3) compelted the required 10 hours of initial training prior to assisting residents with medications which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2024
	Plan of Correction
1 2 3 4	LIcensee stated to provide the required 10 hours of Medication Training to S2 and S3/or proof of S2 and S3 enrollment to complete the required 10 hours of medication training and submit proof to LPA Brown on 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

Page: 6 of 59

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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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 331881142
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(8)(A)

Incidental Medical and Dental Care Services

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency maitained at the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2024
	Plan of Correction
1 2 3 4	Licensee stated to obtain/purchase a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency and submit proof to LPA Brown on Plan of Correction (POC) due date.

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #1 (R1) medications were given according to R1's physician's directions as evidenced of two (2) medications of R1 were not given according to R1's physician's directions which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87465(c)(2) and submit proof of training log to LPA Brown on 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

Page: 7 of 59

Document Has Been Signed on 08/27/2024 06:29 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 331881142
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by allowing Resident #1 (R1) to have a full bed rail and R1's not on hospice and no record of full bed rail exemption approved by CCLD which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2024
	Plan of Correction
1 2 3 4	Licensee removed R1 full bed rail during the visit. Plan of Correction (POC) cleared.

Type A

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #4 (R4) has the annual/updated physician report/medical assessment that's required for dementia residents as evidence d of R2 physician report date of 10/06/2020 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit proof of R4 medical appointment to complete the required annual physician report/medical assessment to LPA Brown on 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

Page: 8 of 59

Document Has Been Signed on 08/27/2024 06:29 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 331881142
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and (record review, the licensee did not comply with the section cited above by not ensuring that the facility has the required updated liability insurance which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2024
	Plan of Correction
1 2 3 4	Licensee stated to obtain and submit a copy of the required liability insurance to LPA Brown on Plan of Correction (POC) due date.

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, interview and record review, the licensee did not comply with the section cited above by not ensuring that Hot water temperature controls were maintained to a temperature in residents bathroom to not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	LIcensee stated to regulate the hot water temperature in residents bathroom to not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C) and submit proof to LPA Brown on 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

Page: 9 of 59

Document Has Been Signed on 08/27/2024 06:29 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 331881142
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(5)

Personal Accommodations and Services

(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that night lights were maintained in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	Licensee stated to obtain/purchase night lights and submit proof to LPA Brown on Plan of Correction (POC) due date.

Type B

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the outdoor passageways were free of obstructions as evidenced of not working stove/oven, washer, microwave blocking the outdoor passageway which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	Licensee stated to remove the not working stove/oven, washer, microwave at the backyard that blocks the outdoor passageway and submit proof to LPA Brown on 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/27/2024 06:29 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 331881142
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #4 (S4) criminal background clearance was transferred at the facility prior to employment which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	Licensee stated to transfer S4 criminal background clearance to the facility and submit proof to LPA Brown on Plan of Correction (POC) due date.

Type B

Section Cited

CCR

87613(a)(2)(B)

General Requirements for Restricted Health Conditions

(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (B) Training shall be completed prior to the staff providing services to the resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring that the required trainings were provided to Staff #2 (S2) and Staff #3 (S3) prior to providing services to residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit Signed Statement of Understanding on CCR 87613(a)(2)(B) to LPA brown on 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

Page: 11 of 59

Document Has Been Signed on 08/27/2024 06:29 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 331881142
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(c)(9)

Other Provisions

(c) The training shall include, but not be limited to, all of the following: (9) Cultural competency and sensitivity in issues relating to the underserved, aging, lesbian, gay, bisexual, and transgender community. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that cultural competency and sensitivity in issues relating to the underserved, aging, lesbian, gay, bisexual, and transgender community training were provided to Staff #2 (S2) and Staff #3 (S3) which poses/ a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	Licensee stated to have S2 and S3 complete the required Cultural competency and sensitivity in issues relating to the underserved, aging, lesbian, gay, bisexual, and transgender community training and submit proof to LPA brown on PLan of Correction (POC) due date.

Type B

Section Cited

CCR

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 his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not completeing the required Pre-Admission Appraisal for Resident #1 (R1) and Resident #2 (R2) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit Signed Statement of Understanding to CCR87457(c) to LPA Brown on 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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

Page: 12 of 59

Document Has Been Signed on 08/27/2024 06:29 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE, LLC	FACILITY NUMBER: 331881142
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(a)(2)

Other Provisions

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Emergency Supplies/Kit, Emergency Food and Emergency Water were maintained at the facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	Licensee stated to obtain and prepare the required Emergency Supplies/Kit, Emergency Food and Emergency Water and submit proof to LPA Brown on Plan of Correction (POC) due date.

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above allowing Resident #3 (R3) to have half bed rail and there's no written order from R3 physician indicating the need for half bed rail for mobility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2024
	Plan of Correction
1 2 3 4	Licensee removed R3 half bed rail during the facility visit. Plan of Correction (POC) cleared.

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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

Page: 13 of 59