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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602155
Report Date: 05/31/2024
Date Signed: 05/31/2024 12:21:06 PM


Document Has Been Signed on 05/31/2024 12:21 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:TWIN OAKS MANORFACILITY NUMBER:
374602155
ADMINISTRATOR:LOLITA V. GATMAITANFACILITY TYPE:
740
ADDRESS:1719 MEDINAHTELEPHONE:
(760) 798-1588
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY:5CENSUS: 3DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Grace Romero, CaregiverTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George conducted an unannounced visit to the facility for the purpose of conducting a 1 year required visit/annual inspection. LPA George met with Caregiver Grace Romero and informed her of the purpose of today's visit. The Administrator was unable to come to the facility during LPAs visit. Below is a summary of what was observed during today’s inspection:

Infection Control: LPA observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents.

Physical Plant: LPA toured the interior and exterior of the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. The facility was observed to have the required furniture and linen to be present and in good condition in resident bedrooms. The exits are free from obstruction and that there is plenty of space for activities. There are no pools or bodies of water on the premises.

Staff Records Review: LPA verified staff present at the facility to have criminal record clearance and to be associated to the facility. LPA observed facility staff to have received initial training, but no subsequent or refresher training's to confirm they are able to perform their required duties. In addition staff present was observed to have have expired CPR/First Aid Certification as 5/13/24. Deficiency cited. The administrator certificate expires on 12/5/24.

Resident Records Review: LPA conducted a review of all 3 resident files and observed for required information present in their files, such as Physician's Report, Admissions Agreement. However no updated appraisals to have been present or completed. Deficiency cited.



Food Services: The kitchen and dining area to be maintained in a clean and healthful manner. Sufficient dishware and silverware were present for resident’s use. LPA observed the facility to have the required amount of 7 day supply non-perishable and a two supply perishable food items. In addition the facility was observed to have 18 expired food items ranging from salad dressing to cake mix, crackers and seasoning, rice and pudding. Some of the expiration dates go as far back as November 2014. Deficiency cited.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: TWIN OAKS MANOR
FACILITY NUMBER: 374602155
VISIT DATE: 05/31/2024
NARRATIVE
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Medication: Resident medication was observed to be locked in a steel file cabinet located inside the kitchen that and is inaccessible to residents. A review of medication revealed that the medication is being given as prescribed as evidenced by the Medication Authorization Record (MAR) and medication (bubble packs and or pill bottle).

Emergency Disaster Preparedness: The facility has an Emergency Disaster Plan on file. LPA observed for the facility to not conduct disaster drills on a quarterly basis. The last documented drill was conducted on 12/15/21. Deficiency cited. The smoke and carbon monoxide detectors were tested and were found to be operable. The facility has 1 fully charged fire extinguisher. There are no known guns or ammunition on the premises. The hot water was tested and was found to be within regulatory limit measuring at 116 degrees Fahrenheit. The sharps and hazardous chemicals were observed to be locked and inaccessible to residents in care.

The Licensee/Administrator Lolita Gamitan will submit a copy of liability insurance to the department by 5pm on 6/1/124.

An exit interview was conducted and a copy of this report, 809D, appeal rights LIC9098-Proof of Corrections form were provided to Grace Romero, Caregiver.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 05/31/2024 12:21 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: TWIN OAKS MANOR
FACILITY NUMBER: 374602155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 1 out of 1 times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2024
Plan of Correction
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The Licensee agrees to have S1 to enroll and complete CPR/first aid training and submit proof of completion. Proof of enrollment is to be submitted to the department by 5pm on the due date indicated 6/1/24.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 1 out of 1 times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2024
Plan of Correction
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The Licensee agrees to conduct an emergency disaster drill. Proof of the drill is to be submitted to the department by 5pm on the due date indicated 6/1/24.
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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 05/31/2024 12:21 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: TWIN OAKS MANOR
FACILITY NUMBER: 374602155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records review the licensee did not comply with the section cited above in 2 out of 2 times which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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The licensee agrees to have staff complete and on going dementia training. Proof (sign in sheet, certificate) is to be submitted to the department by 5pm on the due date indicated 6/14/24.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above 18 out of 18 times, as there were 18 expired food items. Observed during LPAs visit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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The Licensee agrees to check for any additional expired food and discard the items. No POC is due as the 18 item were discarded at the time of LPAs visit.
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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 05/31/2024 12:21 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: TWIN OAKS MANOR
FACILITY NUMBER: 374602155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review , the licensee did not comply with the section cited above in 2 out of 2 times which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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The Licensee agrees to complete reappraisals for current residents. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5