445202247-8-11-2021-26-AS-SYIP-C68LYL-20210825091027

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202247
Report Date: 08/03/2021
Date Signed: 08/11/2021 04:44:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/21/2020 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200221152049

FACILITY NAME:	TWIN LAKES MANOR		FACILITY NUMBER:	445202247
ADMINISTRATOR:	JOSE A. MAGALLAN		FACILITY TYPE:	740
ADDRESS:	777 VOLZ LANE		TELEPHONE:	(831) 477-1100
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	12	CENSUS: 5	DATE:	08/03/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Jennifer Flores		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Facility staff is verbally abusive to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent complaint investigation visit to deliver the finding. LPA met with the Administrator Jennifer Flores.

On 02/26/2020, LPA Gladys Kuizon conducted an initial unannounced complaint investigation. LPA interviewed 1 staff and obtained a copy of staff schedule, residents’ roster, and residents’ care plans. On 06/24/2020, LPA James Santos interviewed 3 residents and 2 staff. Between 03/25/2021 and 04/14 /2021, LPA Yatfai Eric Ng interviewed 4 staff including 2 who were previously interviewed. LPA Ng also attempted to interview 5 new residents but all five were either sleeping, not able to communicate, or refused to be interviewed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 26-AS-20200221152049

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TWIN LAKES MANOR	FACILITY NUMBER: 445202247
	VISIT DATE: 08/03/2021

NARRATIVE

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On 06/24/2020, 3 residents were interviewed. 3 out of 3 residents denied being verbally abused by staff.

Between 06/24/2020 and 04/14/2021, 5 staff were interviewed. 5 out of 5 staff denied being verbally abusive to residents. 5 out of 5 staff denied seeing other staff being abusive to residents.

Based on interviews, the department has determined that the allegation was UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

This report was reviewed with Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/21/2020 and conducted by Evaluator Yatfai Ng

COMPLAINT CONTROL NUMBER: 26-AS-20200221152049

FACILITY NAME:	TWIN LAKES MANOR		FACILITY NUMBER:	445202247
ADMINISTRATOR:	JOSE A. MAGALLAN		FACILITY TYPE:	740
ADDRESS:	777 VOLZ LANE		TELEPHONE:	(831) 477-1100
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	12	CENSUS: 5	DATE:	08/03/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Jennifer Flores		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Facility mismanages residents' medications.

INVESTIGATION FINDINGS:

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12
13

Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent complaint investigation visit to deliver the finding. LPA met with the Administrator Jennifer Flores.

On 02/26/2020, LPA Gladys Kuizon conducted an initial unannounced complaint investigation. LPA interviewed 1 staff and obtained a copy of staff schedule, residents’ roster, and residents’ care plans. On 06/24/2020, LPA James Santos interviewed 3 residents and 2 staff. Between 03/25/2021 and 04/14 /2021, LPA Ng interviewed 4 staff including 2 who were previously interviewed. LPA Ng also attempted to interview 5 new residents but all five were either sleeping, not able to communicate, or refused to be interviewed.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 26-AS-20200221152049

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TWIN LAKES MANOR	FACILITY NUMBER: 445202247
	VISIT DATE: 08/03/2021

NARRATIVE

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On 06/24/2020, 3 residents were interviewed. 3 out of 3 residents denied seeing their medications left on the bed or table.

Between 06/24/2020 and 04/14/2021, 5 staff were interviewed. 5 out of 5 staff denied mismanaging medications. All 5 staff stated they ensure residents take their medication and no medication was left in the rooms. All 5 staff stated they initialed the medication administration record (MAR) when assist with medications. Any medication not administrated would be initialed with a circle around it.

Based on reviews of 5 Medication List and Orders (MLOs) from physicians against the Medication Administration Records (MARs), 5 out 5 MLOs did not align with MARs. 5 out of 5 MARs had medications that were not on MLOs or MARS did not have medications that were prescribed on MLOs.

Reviewing 5 MARs of residents from February 2020 to May 2020, it showed that only 1 out of 5 MARs had complete record. 4 out of 5 MARs showed that there were dates that were left blank without any indication of what happened to that medication or any doctor’s notes for discontinuation or put on hold. These MARs did not accurately match the doctors’ prescription.

Former administrator (S6) was interviewed and per S6, only 2 staff (S6 & S7) were administering, recording, and preparing medications. However, S6 did not have proof of medication training record.

Based on the record review, the preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED, which means that the allegation did occur.

Deficiencies were cited today per California Code of Regulations, Title 22, Division 6. See LIC 809-D. A copy of this report and appeal rights were given and reviewed with Administrator.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20200221152049

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TWIN LAKES MANOR	FACILITY NUMBER: 445202247
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/17/2021 Section Cited CCR 87506(b)(14)	1 2 3 4 5 6 7	87506 Resident Records (b) Each resident’s record shall contain at least the following information: (14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee is to audit all MARs and to provide an audit report to the Department by POC due date.
	8 9 10 11 12 13 14	Based on record review, 4 out of 5 Medication Administration Records (MAR) were incomplete. many dates were left blank with no explanation and no doctor’s notes to stop the medications, and 5 out of 5 did not match the doctor’s scripts. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 08/17/2021 Section Cited HSC 1569.69(a)(1)	1 2 3 4 5 6 7	1569.69(a)(1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training… This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to ensure all staff assisting residents with self administration of medications have completed the required medication training by auditing staff med training records and submit the report to the Department by POC due date.
	8 9 10 11 12 13 14	Based on record review and interview, S6 who assisted with medications did not have proof of completion of 24 hours of initial medication training which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5