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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530062
Report Date: 08/24/2024
Date Signed: 08/24/2024 02:19:41 PM


Document Has Been Signed on 08/24/2024 02:19 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:TWIN HEARTS SENIOR CARE IIFACILITY NUMBER:
335530062
ADMINISTRATOR:MANGENTE, KRISTINEFACILITY TYPE:
740
ADDRESS:342 E OLIVE STREETTELEPHONE:
(951) 373-9122
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY:6CENSUS: 6DATE:
08/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Licensee/Administrator Kristine MangenteTIME COMPLETED:
02:15 PM
NARRATIVE
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On 08/24/2024 at 08:45 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a Case Management Visit. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there were two (2) staff present, and six (6) residents present. Licensee/Administrator Kristine Mangente was contacted and informed of the visit. Licensee/Administrator Mangente arrived during the visit. LPA Brown explained the purpose of the visit to Licensee/Administrator Mangente.

The facility is a four (4) bedroom, two (2) bathroom home with a kitchen/dining area, living room, activity room and laundry area. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory residents. The facility has six (6) Hospice Waiver. The current census is six (6) residents. LPA Brown was accompanied by Staff #2 (S2) and Licensee/Administrator Mangente to conduct a Case Management visit, which included, but was not limited to the following:


The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. LPA Brown observed sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms.

***Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2024
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: TWIN HEARTS SENIOR CARE II
FACILITY NUMBER: 335530062
VISIT DATE: 08/24/2024
NARRATIVE
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Moreover, during the tour of the facility, LPA Brown observed multiple bottles of chemicals not locked, and accessible to residents in care. Deficiency will be issued. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 109 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area.

Furthermore, during the tour of the facility, LPA Brown observed Staff #2 (S2) working at the facility with criminal background clearance but S2 criminal background clearance was not transferred to the facility. Deficiency will be issued and civil penalty will be assessed of $500.00 and will continue to be assessed of $100.00 until corrected. Also, LPA Brown observed Staff #3 (S3) working at the facility without criminal background clearance. Deficiency will be issued and civil penalty will be assessed of $500.00 and will continue to be assessed of $100.00 until corrected.

Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility.

The facility has an administrator present in the facility. LPA Brown did not observed sufficient number of staff to provide care and supervision to the residents in care as no staff scheduled to work the night shift as required for facility with dementia residents. Deficiency will be issued.

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Licensee/Administrator Kristine Mangente.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/24/2024 02:19 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: TWIN HEARTS SENIOR CARE II
FACILITY NUMBER: 335530062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2024
Section Cited
CCR
87309(a)

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87309 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.
This requirement is not met as evidenced by:
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Licensee immediately removed and locked the multiple bottles of chemicals under the sink during the visit. Plan of Correction (POC) cleared.
Licensee stated to train all staff on CCR 87309(a) and submit proof of training log to LPA Brown on POC due date.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the multiple bottle of chemicals under the sink were locked which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
08/25/2024
Section Cited
CCR87355(d)(3)

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87355(d)(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.
This requirement is not met as evidenced by:
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Licensee stated to remove Staff #3 (S3) at the facility today and submit an updated Personnel Summary (LIC500) without S3 on schedule to LPA Brown on POC due date.
Licensee stated to obtain S3 criminal background clearance before allowing S3 to work back at the facility.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) obtain a criminal background clearance prior to employment 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) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/24/2024 02:19 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: TWIN HEARTS SENIOR CARE II
FACILITY NUMBER: 335530062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2024
Section Cited
CCR
87705(c)(4)(A)

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87705 Care of Persons with Demetia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.
This requirement is not met as evidenced by:
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Licensee stated to submit an updated staff schedule/Personnel Summary (LIC500) showing that there's a night shift staff working at the facility, awake and on duty to LPA brown on Plan of Correction (POC) due date.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's a staff scheduled to work the shift, awake and on duty as required for facility with dementia residents which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
09/03/2024
Section Cited
CCR87355(e)(3)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as evidenced by:
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Licensee stated to transfer S2 criminal background clearance to the facility and submit proof to LPA brown on POC due date.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #2 (S2) criminal background clearance was transferred at the facility prior to employment 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) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4