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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700850
Report Date: 10/17/2023
Date Signed: 10/17/2023 01:07:44 PM

Document Has Been Signed on 10/17/2023 01:07 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: 15DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:43 AM
MET WITH:Kyle Boulliez TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required inspection. LPA met with facility staff Kyle, and explained the purpose of the visit. LPA spoke to licensee via cell phone. At the end of the visit, LPA met with Licensee/Administrator Linda.

LPA toured the physical plant to ensure compliance with Title 22 regulations. LPA observed facility staff making breakfast. Today breakfast was a hash brown, scrambled eggs with chorizo and spinach, coffee, milk, juice, and water. Medications were observed to be locked and inaccessible to residents in care. LPA observed facility staff pass out medications to the residents in care. LPA toured the facility with facility staff Kathy. LPA observed common areas, resident bedrooms, resident bathrooms, staff areas, and outside common areas. Resident bedrooms had required furniture and furnishings. Technical Assistance was provided for the chairs. Bathrooms were observed to be in working condition. Hot water was measured at 110.8*F. The outside area of the home had areas for residents to smoke, garden, and enjoy the outside. The facility has a fenced and locked pool area. The pool does not have water and will not be used. Lunch was observed to be sandwiches, fruit, chips and drink of choice. LPA observed fire extinguishers, a fire pull alarm system, and carbon dioxide detectors to be in working condition. The last fire drill was completed on 10/01/2023.The thermostat for the facility temperature read 73*degrees F.

LPA reviewed resident, staff, and facility files. Administrator Certificate for Linda Mustin #6055825735 Expires on 03/26/24. First aid certificates were not located in the files; however, when asked by LPA, staff were able to show their cards showing an expiration of 2024. LPA observed 5 resident files. 2 resident files did not have an updated LIC 602. LPA requested the following annual documentation: LIC 500, LIC 308, LIC 610E, Administrator Certificate, Proof of Control of Property
Per California Code of Regulations (CCR) - Title 22, deficiencies were observed today. Appeal Rights Provided. An exit interview was held, and a copy of the report was provided to Licensee.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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 10/17/2023 01:07 PM - It Cannot Be Edited


Created By: Christina Valerio On 10/17/2023 at 12:45 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: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 2 out of 5 resident files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Licensee will make appointments for the residents without an updated LIC 602. Licensee to send LPA confirmation of appointments and confirmation of when the LIC 602's have been updated.
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:Stephen Richardson
LICENSING EVALUATOR NAME:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
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