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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881142
Report Date: 08/21/2025
Date Signed: 08/21/2025 02:37:02 PM

Document Has Been Signed on 08/21/2025 02:37 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/
DIRECTOR:		MANGENTE, KRISTINE A.FACILITY TYPE:
740
ADDRESS:995 BOUQUET CIR.TELEPHONE:
(951) 736-6925
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 6CENSUS: 3DATE:
08/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Staff- Mildred Manuel and Staff- Marionito Delacruz TIME VISIT/
INSPECTION COMPLETED:
02:40 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 staff Mildred Manuel and Marionito M Delacruz and was granted entry to the facility. The Administrator Krisitine Mangente was contacted and informed about today’s visit. 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 three (3). LPA was accompanied by staff Mildred Manuel 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 was not maintained at a comfortable temperature. The outside temperature was 101 degrees F and the inside temperature of the facility was 88 degrees F. S1 and S2 informed LPA that the AC unit has been broken for three days. Fans will be placed throughout the facility until cool air is provided. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting. The bathrooms, kitchen and dining area were not clean. LPA Rico observed a cockroach inside a resident’s bathroom. LPA Rico also observed cockroaches inside the kitchen area. Facility’s floor surfaces in the bathroom, kitchen and hallways were observed dirty. In addition, LPA observed the facility did not have emergency supplies.

Furthermore, 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 resident/staff files. Medications are kept inaccessible to clients.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Mary Rico
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2025
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 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/21/2025 02:37 PM - It Cannot Be Edited


Created By: Mary Rico On 08/21/2025 at 12:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interviews the licensee did not comply with the section cited above by having AC broken, S1 and S2 stated the AC has been broken for three days which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2025
Plan of Correction
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The Licensee has agreed to repair AC and send proof of invoice to LPA Rico.
Type A
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having kitchen, bathroom and hallway floors dirty which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2025
Plan of Correction
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The Licensee has agreed to clean the floor surfaces in the kitchen, bathrooms and hallways. Licensee will submit proof to LPA Rico.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2025


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 08/21/2025 02:37 PM - It Cannot Be Edited


Created By: Mary Rico On 08/21/2025 at 12:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having cockroaches in the kitchen area and bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2025
Plan of Correction
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The Licensee has agreed to have a pest control come to their facility. A copy of the invoice will provided to LPA Rico.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record, the licensee did not comply with the section cited above by transfering R1 and R2 medication to a Monday through Friday container which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2025
Plan of Correction
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The Licensee has agreed to train staff on medication and will remove the Monday through Friday container.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 08/21/2025 02:37 PM - It Cannot Be Edited


Created By: Mary Rico On 08/21/2025 at 12:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having R1 PRN documented along with resident's response which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2025
Plan of Correction
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The Licensee stated they will create R1 PRN MAR which will include resident's response. Staff will also recieve training. A copy will be provided to LPA Rico.
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.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 08/21/2025 02:37 PM - It Cannot Be Edited


Created By: Mary Rico On 08/21/2025 at 12:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by S1 and S2 did not have a copy of the Health Screening which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
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Licensee has agreed to have send S1 and S2 Health Screening.
Type B
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by S2 not having training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
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The Licensee has agreed to provide S2 job training, and will send proof to LPA Rico.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 08/21/2025 02:37 PM - It Cannot Be Edited


Created By: Mary Rico On 08/21/2025 at 12:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above by not conducting emergency drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
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Licensee has agreed to conduct an all staff emergency drill and will send proof to LPA Rico.
Type B
Section Cited
HSC
1569.695(f)(2)(D)
Other Provisions
(f) A facility shall have both of the following in place: (2) A set of keys available to facility staff on each shift for use during an evacuation that provides access to all of the following: (D) All facility cabinets and cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above by not having emergency supplies which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
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2
3
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The Licensee has agreed to have emergency supplies and send proof to LPA Rico
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 08/21/2025 02:37 PM - It Cannot Be Edited


Created By: Mary Rico On 08/21/2025 at 12:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(b)(2)

87303(b)(2) Maintenance and Operation
The facility shall cool rooms to a comfortable range, between 78degrees F(26 degrees C) and 85 degrees F (30 degrees C) or in areas of extreme heat to 30degrees F less than the outside temperature.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by not having the the rooms cool, the temperature inside was 88 degrees F and the outside temperature was 101 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2025
Plan of Correction
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2
3
4
The Licensee stated they will have someone repair the AC and place fans inside the residents room for cooler temperature
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:
Mary Rico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
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: 08/21/2025
NARRATIVE
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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.

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 R1 PRN medications have not been documented, along with resident’s response. In addition, LPA Rico also observed medications were transferred to a Monday through Friday container. LPA Rico observed S1 and S2 did not have their Health Screening and S2 did not have job training. Furthermore, S1 and S2 had criminal record clearance and CPR/First Aid training completed.

Based on the observations made during today’s visit, ten (10) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report (LIC809), LIC809D, LIC9102, LIC421FC, LIC421BG and Appeal Rights were discussed and provided to Staff Mildred Manuel and House Manager Susan Nuguid.

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Mary Rico
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC809 (FAS) - (06/04)
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