<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881142
Report Date: 05/21/2025
Date Signed: 05/21/2025 11:00:57 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/14/2025 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250114090200
FACILITY NAME:TWIN HEARTS SENIOR CARE, LLCFACILITY NUMBER:
331881142
ADMINISTRATOR:MANGENTE, KRISTINE A.FACILITY TYPE:
740
ADDRESS:995 BOUQUET CIR.TELEPHONE:
(951) 736-6925
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY:6CENSUS: 0DATE:
05/21/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Kristine MangenteTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff failed to provide resident's records to authorized representative.
Facility did not provide a refund upon resident’s death.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 deliver the findings of the above allegations. LPA Rico explained the purpose of the requested Office Visit. The investigation consisted of staff interviews and record review.

For the allegation, Facility staff failed to provide resident's records to authorized representative.

During staff interviews, S1 confirmed they had received a call, formal letters and via-email request from R1 authorized representative. S1 admitted they did not provide resident’s records to authorized representative because they had assumed they were not allowed to. In addition, S2 stated S1 was responsible to provide R1 records to authorized representative and was aware R1’s representative had contact facility staff members.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 56-AS-20250114090200
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, LLC
FACILITY NUMBER: 331881142
VISIT DATE: 05/21/2025
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
26
27
28
29
30
31
32
For the allegation, Facility did not provide a refund upon resident’s death.

During staff interview, S1 indicated R1 had moved to the facility on 2/26/2024 had passed away on 2/29/2024. In addition, S1 indicated R1’s responsible party had made a payment of 4,500 and no reimbursement was provided. S1 indicated no copy of Admission Agreement and pre-admission were provided to R1’s family and R1 had moved their personal belongings on 2/29/2024.

During record review, LPA verify the facility had received a certified formal letter request on 9/9/2024 from R1’s authorized representative for R1’s records along with reimbursement. In addition, LPA verify the R1’s Admission Agreement was incomplete, the fee charges and refund conditions was missing.

Based on the evidence gathered during today’s investigation, the TWO (2) allegations listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegation are valid because the preponderance of evidence the standard has been met.

During today’s visit, two (2) deficiency were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to Licensee Kristine A. Mangente along with a copy of the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20250114090200
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, 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
87506(c)(1)
1
2
3
4
5
6
7
87506(c)(1)Resident Records. (c) All information and records..The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative..This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee has agreed to read regulation entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to train staff on resident records and has agreed to provide LPA proof that the legal conservator was given the documents requested.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above by not providing R1's respresentative records, which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
POC due date 5/28/2025
Type B
05/28/2025
Section Cited
HSC
156.9652(e)(1)(b)
1
2
3
4
5
6
7
Health and Safety Code section 1569.652 (e) (1)(b)1.A 100 percent refund of a preadmission fee shall be provided.. representative if:b.The licensee fails to provide full written. and refund ...This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee has agreed to read regulation entirely and send LPA a self-certified letter that the regulation was read and understood.
LPA proof that the legal conservator was given R1's reimbursment.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above by not providing R1's respresentative records, which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3