374603887-7-22-2024-18-AS-JARA-D7ESJH-20240722135511

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603887
Report Date: 07/22/2024
Date Signed: 07/22/2024 01:55:15 PM

Document Has Been Signed on 07/22/2024 01:55 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 GARDEN III		FACILITY NUMBER:	374603887
ADMINISTRATOR:	LUKIC, TANJA DRAGANA		FACILITY TYPE:	740
ADDRESS:	1950 EDWIN LANE		TELEPHONE:	(760) 803-7218
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92069
CAPACITY:	6	CENSUS: 6	DATE:	07/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Administrator, Tanja Lukic		TIME COMPLETED:	02:10 PM

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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Tanja Lukic, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (4) resident present.

The facility is a one story home with (7) bedrooms and (3) bathrooms with attached garage. (6) bedrooms are for the residents. No pools or firearms are being kept at the facility.

Infection Control: The LPA observed the hand washing sinks and kitchen, PPE equipment, and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements.

Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The hot water temperature was recorded in the resident bathroom at 108.6F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

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 GARDEN III	FACILITY NUMBER: 374603887
	VISIT DATE: 07/22/2024

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Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Required postings were found in the facility. The listed administrator, possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed (3) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in kitchen cabinet. LPA reviewed client medications for (2) client and found all medications accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire drill May 16, 2024, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit.

No deficiencies were cited at the time of the visit. An exit interview was conducted where this report was reviewed and provided.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC809 (FAS) - (06/04)

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