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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603112
Report Date: 10/12/2022
Date Signed: 10/12/2022 04:45:20 PM


Document Has Been Signed on 10/12/2022 04:45 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:TWAIN RESIDENTIAL CARE, LLCFACILITY NUMBER:
374603112
ADMINISTRATOR:SIMSUANGCO, LEONARDOFACILITY TYPE:
740
ADDRESS:4626 TWAIN AVETELEPHONE:
(619) 281-8337
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:12CENSUS: 8DATE:
10/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Administrator Leonardo SimsuangcoTIME COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Kayla Hilario conducted an unannounced Case Management visit. LPA identified herself, discussed the purpose of the visit. LPA was allowed entry by caregiver Edmund Patawaran and met with caregiver Reynaldo Abit. Administrator Leonardo Simsuangco arrived during the visit.

The Care Provider Management Bureau (CPMB) submitted an Order to Individual of Immediate Exclusion, dated 09/16/2022 for Individual #1 (I1). [See LIC 811 Confidential Names List for a description of I1].

Administrator Leonardo Simsuangco confirmed that I1's employment was terminated on 09/07/2022, with I1 receiving his last employment paycheck dated 09/15/2022. LPA confirmed that I1 was not included with with batch of employee paychecks stubs for 09/16/2022- 09/30/2022.

No deficiencies were cited or observed on this date.

An exit interview was conducted with Leonardo Simsuangco to whom copy of this report and appeal rights (LIC 9058 03/22) were provided via hardcopy at the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla HilarioTELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
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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