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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700850
Report Date: 10/27/2021
Date Signed: 10/27/2021 03:22:24 PM

Document Has Been Signed on 10/27/2021 03:22 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:TWIN CITIES BOARD & CARE HOMEFACILITY NUMBER:
342700850
ADMINISTRATOR:LINDA MUSTINFACILITY TYPE:
735
ADDRESS:11098 TWIN CITIES ROADTELEPHONE:
(209) 745-4380
CITY:GALTSTATE: CAZIP CODE:
95632
CAPACITY: 15CENSUS: 14DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Linda MustinTIME COMPLETED:
03:00 PM
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On 10/27/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced 1-year required infection control inspection. At approximately 12:00 PM, LPA met with a staff member and explained the purpose of the visit. LPA was sanitized following the facility's entrance health and safety procedures. LPA also had his temperature checked and logged and then signed into the facility.

At approximately 1:00 PM, LPA met with Administrator Linda Mustin and conducted a tour of the facility with the Administrator. The physical plant is consistent with the submitted facility floor plan and has the COVID-19 health and safety signage. There are no obstructions blocking indoor and outdoor passageways. No pools or bodies of water observed. The facility's kitchen is free of debris. Facility refrigerator is stocked with meats, eggs, vegetables, milk, and fruit. Seven-day non-perishable food supply and two-day perishable food supply is sufficient. At 1:25 PM, LPA observed the facility's restrooms as clean and equipped with hand washing signage. The facility's backyard was free of debris.

The clients' bedrooms were inspected and all had the required lighting and furniture. Facility was equipped with smoke detectors and carbon monoxide detectors. LPA also observed the fire extinguisher as current. The facility's first aid kit included the required tweezers, scissors, and a thermometer. Cleaning solutions are stored and locked. Medication supply is also stored and locked. PPE supply is sufficient, as stated by the Administrator. Additional wipes and sanitizer are stored in the garage.

At approximately 1:30 PM, LPA completed the tour of the facility and began writing this report. LPA reviewed facility procedures for visitation entrance, temperature checks and logs, COVID-19 isolation, PPE, food and cleaning supply storage.

Based on LPA’s observations, record review, and interview, which were conducted along with a file review, the preponderance of evidence has been met. California Code of Regulations (Title 22, Division 6 & Chapter number 6) is being cited on the attached LIC 9099D.

No deficiencies were cited today. Exit interview conducted with Administrator. A copy of this report will be emailed to the facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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 10/27/2021 03:22 PM - It Cannot Be Edited


Created By: Mohamed Filouane On 10/27/2021 at 02:57 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: TWIN CITIES BOARD & CARE HOME
FACILITY NUMBER: 342700850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85604(h)


This requirement is not met as evidenced by: The Licensee failed to ensure their administrator certificate is current.
Deficient Practice Statement
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(h) Certificates shall be valid for a period of two (2) years and expire on either the anniversary date of initial issuance or on the individual's birthday during the second calendar year following certification.

Based on record review, interview, and file review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2021
Plan of Correction
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The Licensee shall submit the required documents to the Department to renew their administrator certificate.
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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Mohamed Filouane
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
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