335530062-2-16-2024-56-AS-RGAR-D2HQFM-20240216110810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530062
Report Date: 02/16/2024
Date Signed: 02/16/2024 11:08:16 AM

Document Has Been Signed on 02/16/2024 11:08 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 II		FACILITY NUMBER:	335530062
ADMINISTRATOR:	MANGENTE, KRISTINE		FACILITY TYPE:	740
ADDRESS:	342 E OLIVE STREET		TELEPHONE:	(951) 373-9122
CITY:	CORONA	STATE: CA	ZIP CODE:	92879
CAPACITY:	6	CENSUS: 6	DATE:	02/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Kristine Mangente- Administrator		TIME COMPLETED:	11:18 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Kristine Mangente and was granted entry to the facility. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory residents. The current census is six (6) residents. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the bathrooms to be at 112.2 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, 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 the residents in care. There was a designated storage space for resident files and staff files. The medications are stored inside a closet near the living room inaccessible to the residents. During medication review, LPA found that the Resident’s R1, R2, R3, and R4 had medications that were removed out of their originally received prescription containers and were being stored in a plastic container cups. The facility will be issued a deficiency for not storing the resident’s medications in the original prescription containers. Non-perishable and perishable food supply is sufficient for the residents in care. The pool and spa in backyard is locked and inaccessible to the residents.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

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 02/16/2024 11:08 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 II	FACILITY NUMBER: 335530062
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	This requirement is not met as evidenced based on observation and interview, the licensee did not comply with the section cited above evidenced by removing the resident R1, R2, R3, & R4 medications out of their originally received prescription containers and storing the resident’s medications in a plastic container cups which poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 02/17/2024
	Plan of Correction
1 2 3 4	The licensee has agreed to read regulation 87465 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed that moving forward the resident’s medications will be stored in the original received prescription containers. The licensee has agreed to conduct a medication training with the staff and send LPA proof of attendance. POC is due by 2/17/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 02/16/2024

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LPA reviewed six (6) residents files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed three (3) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings.

Based on the observations made 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, and this report (LIC809), LIC811, and LIC809D were discussed and provided to Administrator Kristine Mangente, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan Gardner	TELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2024

LIC809 (FAS) - (06/04)

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