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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603112
Report Date: 08/18/2022
Date Signed: 08/18/2022 11:11:22 PM


Document Has Been Signed on 08/18/2022 11:11 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: 12DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Licensee, Chona SimsuangcoTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Correia conducted an unannounced annual inspection. LPA Correia identified herself, and was allowed entry to the facility by Licensee Chona Simsuangco.

LPA conducted a tour of the facility, accompanied by Licensee Simsuangco, to ensure compliance with the Department’s Infection Control Policy. LPA provided technical assistant and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808).

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; A sign-in policy enacted for all visitors; Face coverings worn by staff; Hand sanitizer/hand washing stations readily available; A designated visitation area; Emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. No deficiencies were observed during today's visit.
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An exit interview was conducted with Licensee Simsuangco to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided. Signature on this form confirms receipt of the reports.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2022
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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