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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881142
Report Date: 07/28/2023
Date Signed: 07/28/2023 07:08:49 PM


Document Has Been Signed on 07/28/2023 07:08 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



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: 6DATE:
07/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Kristine A. MangenteTIME COMPLETED:
07:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Administrator Kristine Mangente and was granted entry to the facility. The facility is a six (6) bedroom, three (3), bathroom facility, with a kitchen/dining area, living area and attached garage. Licensed capacity is six (6) current census 6 (6). LPA was accompanied by Facility Administrator Brittany Martinez 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 (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 119 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated storage space for client/staff files. Medications are kept inaccessible to clients. LPA observed Administrator's cousin who in not fingerprint clearance has been living in the second-floor bedroom .

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
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 07/28/2023 07:08 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
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: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87355(d)(3)
Criminal Record Clearance
(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the Administrator did not comply with the section cited above in obtaining criminal record clearance for two(2) staff and on (1) cousin has been living at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2023
Plan of Correction
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Licensee has agreed to send information to LPA via email.
The licensee has agreed to send LPA documented proof that the one (1) occupant has vacated the building
Deficiency Dismissed
Type A
Section Cited
CCR
87355(e)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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.Based on observation, interview and record review, the Administrator did not comply with the section cited above in obtaining criminal record clearance for two(2) staff and on (1) cousin has been living at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/29/2023
Plan of Correction
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The licensee has agreed to send LPA documented proof that the one (1) occupant has vacated the building
Licensee has agreed to send information to LPA via email.
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 MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/28/2023
NARRATIVE
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Record Review: LPA reviewed three (3) client files for admission agreements, updated physician reports, and needs and services plans. Medications were audited at random and are not dispensed appropriately by staff members. LPA discovered two (2) clients files are not at the facility. Two (2) staff do not have First Aid/CPR certification, no criminal record clearance, training's, and health screenings.

Based on observations today, a civil penalty in the amount of $500 dollars will be issued for violation of the facilities fire clearance. Based on the observations made during today’s visit, two (2) deficiencies and one civil penalty were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to to Facility Administrator Kristine Mangente , along with a copy of LIC809D, LIC421IM, and the appeal right.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 07/28/2023 07:08 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
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: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465

(3) The date and time the PRN medication was taken, the dosage taken, and the residents response shall be documented and maintained in the resident's facility record
Deficient Practice Statement
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Medication has not been docuemnted
POC Due Date: 07/28/2023
Plan of Correction
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Licensee has agreed to email LPA documentation
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: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4