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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700850
Report Date: 05/30/2023
Date Signed: 05/30/2023 02:17:09 PM

Document Has Been Signed on 05/30/2023 02:17 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
SACRAMENTO AC/SC, 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: 15DATE:
05/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Bouillez, KyleTIME COMPLETED:
01:45 PM
NARRATIVE
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On 05/230/2023 LPA Kesha Lewis arrived unannounced to conduct a case management visit regarding the deficiencies observed during a complaint investigation. LPA met with, staff Kyle and explained the purpose of the visit.

LPA Lewis visited the facility on multiple occasions on one occasion LPA Lewis was in the kitchen area and was speaking to a staff member regarding a complaint and the License called and informed started speaking about what was being said between LPA and staff. The License then stated that there are cameras in all common areas of the facility but only one (1) intercom in the kitchen.

The following deficiencies were cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights and a copy of the report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2023
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 05/30/2023 02:17 PM - It Cannot Be Edited


Created By: Kesha Lewis On 05/30/2023 at 12:13 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: 05/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2023
Section Cited
CCR
80072(a)(1)

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(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:

(1) To be accorded dignity in his/her personal relationships with staff and other persons.
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License will have the intercom removed and a photo sent to LPA for verification. If removal requires profficnal assistance a detailed invoice will be sent to LPA stating what was completed.
As of 4/24/2023 the intercom was removed. LPA looked and verified.
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This is evidenced by observation. LPA observed that there is an intercom in the kitchen where private convocations can be heard. This poses a potential health and safety risk to resident 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:Liza King
LICENSING EVALUATOR NAME:Kesha Lewis
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023


LIC809 (FAS) - (06/04)
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