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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602155
Report Date: 05/29/2025
Date Signed: 05/29/2025 02:39:31 PM

Document Has Been Signed on 05/29/2025 02:39 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/
DIRECTOR:		LOLITA V. GATMAITANFACILITY TYPE:
740
ADDRESS:1719 MEDINAHTELEPHONE:
(760) 798-1588
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY: 5TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
05/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Caregiver, Grace RomeroTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 5/29/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA was greeted and granted entry by Caregiver, Grace Romero who was informed of the purpose of the visit. Grace reported they informed Licensee, Lolita Gatmaitan of LPA's visit at the facility. The facility has a fire clearance to serve five (5) non-ambulatory elderly residents. LPA was informed none of the current residents receive hospice services.

LPA toured the facility with Grace and observed the facility is made up of a one-story home with three (3) resident bedrooms, one (1) bathroom, a kitchen, dining area, living room, laundry room, and attached garage. Resident bedrooms had the required bedding, furniture, and lighting. The bathroom had a grab bar and non-skid mat in the shower. The hot water temperature in the bathroom measured at 116 degrees Fahrenheit. No bodies of water were observed on the premises. Indoor and outdoor pathways were free of obstruction. The facility met Departmental requirements for a two-day supply of perishable foods and seven-day supply of non-perishable foods. Medications are secured in a locked cabinet stored near the kitchen. The facility has additional incontinent supplies, towels, blankets and linens available for resident use. Grace tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed a charged fire extinguisher mounted near the kitchen. Grace has a criminal record clearance, is associated with the facility, and has a valid CPR/AED/first aid certificate expiring on 5/31/2026. Long Term Care Ombudsman's contact information, residents' personal rights, complaint procedures, facility sketch, and emergency disaster plan are posted on a hallway wall leading to the residents' bedrooms. LPA reviewed the facility's certificate of liability insurance, which expired on 3/24/2024. Grace reported they informed licensee who communicated they would search for a more current one at their home. During the visit, licensee/Grace were unable to produce a current copy of the facility's certificate of liability insurance. As a result, the facility will be cited. An exit interview was conducted and a copy of this report, LIC 809-D, and Appeal Rights were reviewed and provided to Grace.

Anthony PerezTELEPHONE: (323) 485-4915
Janette RomeroTELEPHONE: (951) 529-2930
DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/29/2025 02:39 PM - It Cannot Be Edited


Created By: Janette Romero On 05/29/2025 at 02:36 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
, 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: 05/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not being able to produce a current copy of the facility's certificate of liability insurance, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Licensee reported they will email LPA a current copy of the facility's certificate of liability insurance by close of business on 6/6/2025.
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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (323) 485-4915
Janette Romero
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (951) 529-2930
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2025


LIC809 (FAS) - (06/04)
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