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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881142
Report Date: 10/25/2023
Date Signed: 10/25/2023 11:06:06 AM


Document Has Been Signed on 10/25/2023 11:06 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:MANGENTE, KRISTINE A.FACILITY TYPE:
740
ADDRESS:995 BOUQUET CIR.TELEPHONE:
(951) 736-6925
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY:6CENSUS: 6DATE:
10/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Frederic ManuelTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico made a Case Management visit to the facility. The purpose of the visit was to conduct a follow-up regarding staff criminal record clearance. LPA met with Frederic Manuel and Kristine A. Mangente and was granted entry to the facility.

Due to a pervious visit on 7/28/2023, LPA discovered S1, S2, and S3 did not have criminal record clearance. S1 and S2 worked at the facility from 7/21/2023 through 7/28/2023. S3 is Administrator cousin who reside at the facility for a week from 7/24/2023- 7/28/2023.

During today’s visit, LPA conducted a record review and confirmed that S4 does not have a criminal record clearance. During interview it was discovered S4 had volunteer at the facility for a week. LPA informed Administrator and staff that any adults other than a client, residing in the facility shall have a criminal record clearance/exemption. This also includes presence in the facility.

Based on interview, record's review, and observation during today’s visit, one (1) deficiency and one (1) civil penalty in the amount of 2,000 was cited per Title 22, Division 6, of the California Code of Regulations (CCR).

An exit interview was conducted and a copy of this report, LIC 809D, LIC421BG(6/17) and Appeal Rights were provided to Administrator Kristine A. Mangente.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
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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Document Has Been Signed on 10/25/2023 11:06 AM - 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: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2023
Section Cited
CCR
87355(d)(3)

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The licensee shall submit these fingerprints to the California Department of Justice, for comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.
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Administrator shall submit a letter of understanding of regulation cited and understanding that staff shall not return to the facility until S4 has been clearned through Department of Justice.
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Based on observation, interviews and records review, the Licensee did not comply with the section cited above by S4 not having a criminal record clearance the facility, which poses an immediate Health, Safety, or Personal Rights risks to persons in care.
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POC due date by 10/26/2023

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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: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023
LIC809 (FAS) - (06/04)
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