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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881142
Report Date: 01/17/2024
Date Signed: 01/17/2024 11:20:53 AM


Document Has Been Signed on 01/17/2024 11:20 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: 4DATE:
01/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Frederic Manuel- CaregiverTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility for a complaint.

During the visit, LPA observed two (2) gates to the pool in the backyard open and unlocked. LPA was informed by Caregiver Frederic Manuel that the pool company left the gate open and unlocked during a visit on 1/16/2024. The staff leaving the pool gates open and unlocked poses an immediate health, safety, or personal rights risk to persons in care.

During today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report, LIC809, LIC809D, the appeal rights were discussed and provided to Frederic Manuel.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
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 2


Document Has Been Signed on 01/17/2024 11:20 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: 01/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2024
Section Cited
CCR
87705(e)

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87705 Care of Persons with Dementia (e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes.
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The licensee has agreed to read regulation 87705 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to close and lock the gates to the pool. POC is due by 1/18/2024.
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This requirement is not met as evidenced based on interview and observation, the licensee did not comply with the section cited above evidenced leaving the pool gates open and unlocked which poses an immediate health, safety, or personal rights risk to persons in care.
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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) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2