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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881142
Report Date: 11/28/2023
Date Signed: 11/28/2023 11:56:23 AM


Document Has Been Signed on 11/28/2023 11:56 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: 5DATE:
11/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Frederic ManuelTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to the facility for a complaint. During the complaint visit, LPA Rico completed a case management visit to cite for four (4) deficiencies found during facility tour.

During facility tour, LPA observed R1 doorknob is not working. Doorknob does not open and close properly. LPA observed cleaning solutions under the bathroom sink without a lock LPA requested care givers to remove cleaning solutions immediately. In addition, LPA observed expire food inside the refrigerator. LPA requested care givers to remove expire food immediately.

During record review, LPA observed facility did not have planned activities for the month. Planned Activities should also include the following items: socialization, daily living skills, leisure, physical activities, education and free time for their own activities.

During today’s visit, four (4) deficiencies to the facility were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report, LIC809, LIC809D, Appeal Rights were discussed and provided to Frederic Manuel.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary RicoTELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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 3


Document Has Been Signed on 11/28/2023 11:56 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: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2023
Section Cited
CCR
87303(a)

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87303(a) Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times... the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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Licensee will provided proof that doorknob has been repaired.
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Based on observation and interview the licensee did not comply with the section cited above by not having R1 doorknob in good repair which poses a potential health, safety or personal rights risk to persons in care.
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POC due date 12/6/2023
Type B
12/06/2023
Section Cited
CCR87219(a)

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87219(a)Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include:
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Licensee will provide a planned acitivites calendar and include socialization, daily living, leisure time, physical acitvities, arts, crafts, music etc..
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Based on observation and interview the licensee did not comply with the section cited above by not having planned acitivites which poses a potential health, safety or personal rights risk to persons in care.
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POC due date 12/6/2023
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: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/28/2023 11:56 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: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/29/2023
Section Cited
CCR
87309(a)

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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.
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Licensee has agreed to send proof they have read and understood the regulation and will train staff to lock cleaning solutions.
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Based on observation and interview the licensee did not comply with the section cited above evidenced by not having cleaning solutions locked which poses an immediate Health, Safety or personal rights risk to persons in care.
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POC due date 11/29/2023
Type A
11/29/2023
Section Cited
CCR87555(b)(8)

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87555 General Food Service Requirements
(b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
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Licensee has agreed to send proof they have read and understood the regualtion and will train staff to remove food items when expired.
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Based on observation and interview the licensee did not comply with the section cited above evidenced by having expire food
which poses an immediate Health, Safety or personal rights risk to persons in care.
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POC due date 11/29/2023
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: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3