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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530062
Report Date: 11/13/2023
Date Signed: 11/13/2023 02:56:59 PM


Document Has Been Signed on 11/13/2023 02:56 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 IIFACILITY NUMBER:
335530062
ADMINISTRATOR:MANGENTE, KRISTINEFACILITY TYPE:
740
ADDRESS:342 E OLIVE STREETTELEPHONE:
9513739122
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:6CENSUS: 3DATE:
11/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Isidoro Villarente- CaregiverTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced case management visit during complaint control number 56-AS-20231109085136. LPA met with Caregiver Isidoro Villarente and explained the reason for the visit.

During today visit, LPA requested staff files for staff S1 and Staff S2. LPA was informed that S1 and S2 do not have a staff file at the facility. LPA requested resident files for resident R1, R2, and R3. LPA was informed that R1, R2, and R3 do not have a resident file at the facility.

Based on observations today, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.



An exit interview was conducted, and this report was discussed and provided to Caregiver Isidoro Villarente, along with a copy of the appeal rights.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023
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 2


Document Has Been Signed on 11/13/2023 02:56 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 II
FACILITY NUMBER: 335530062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2023
Section Cited
CCR
87506(a)

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87506. Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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The licensee has agreed to read regulation 87506 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to create a file for resident R1, R2, and R3 with all the required documents listed in regulation 87506. The POC is due by 11/17/2023.
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Based on interview, observation, and document review the licensee did not comply with the section cited above evidenced by not having a resident file for resident R1, R2, and R3 in the facility which poses a potential health, safety, or personal rights risk to persons in care
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Type B
11/17/2023
Section Cited
CCR87412(a)

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87412 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:
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The licensee has agreed to read regulation 87506 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to create a file for staff S1 and S2 with all the required documents listed in regulation 87412. The POC is due by 11/17/2023.
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Based on interview, observation, and document review the licensee did not comply with the section cited above evidenced by not having a staff file for staff S1 and S2 in the facility which poses a potential 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: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2