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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202247
Report Date: 08/02/2021
Date Signed: 08/02/2021 05:23:09 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2020 and conducted by Evaluator Marybeth Donovan
COMPLAINT CONTROL NUMBER: 26-AS-20200601092250
FACILITY NAME:TWIN LAKES MANORFACILITY NUMBER:
445202247
ADMINISTRATOR:JOSE A. MAGALLANFACILITY TYPE:
740
ADDRESS:777 VOLZ LANETELEPHONE:
(831) 477-1100
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:12CENSUS: 5DATE:
08/02/2021
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jennifer Flores AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident sustained pressure injuries while in care
Facility failed to notify change of resident condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Marybeth Donovan and Christine Dolores conducted an unannounced visit to deliver the findings to the above allegations. LPA met with Jennifer Flores Administrator.

Between 06/24/2020-07/23/2021 a total of four staff were interviewed. 4 out of 4 staff stated they did not observe any residents with pressure injuries. All staff stated residents are repositioned every 2 hours. All staff interviewed also stated the administrator notifies the resident’s primary care physician and responsible party when the resident has a change of condition.

Between 06/24/2020-07/07/2020 a total of five residents were interviewed. 2 out of 5 residents stated they did not have any pressure injures or open wounds and staff reposition them. Two residents stated staff notify family or responsible party when the resident has a change of condition. Three residents were not able to answer questions regarding pressure injuries, repositioning, and notifications of change of condition.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
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-20200601092250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: TWIN LAKES MANOR
FACILITY NUMBER: 445202247
VISIT DATE: 08/02/2021
NARRATIVE
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On 08/26/2020 and 09/03/2020 a total of three family members were interviewed. 3 out of 3 family members stated they did not observe the resident with any pressure injuries or open wounds, and staff reposition the resident. All family members stated they are in communication with the facility staff regarding the resident’s condition.

On 06/24/2020 LPA toured the facility and did not observe any open wounds or pressure injuries on the residents.

Medical records dated 04/18/2020-05/13/2020 indicated R1’s skin was warm, dry, and no rashes. R1 had wounds and wound care was provided. Medical records did not indicate R1 had any pressure injuries on the body. Physician’s report indicated R1 had a history of skin breakdown and did not note any pressure injuries on the body.

R1’s care plan indicated that the facility notified R1 primary physician on 04/27/2020 and responsible party on 04/23/2020, 04/18/2020, and 05/09/2020 regarding R1’s condition.

This Department has investigated the above allegations, and based on interviews, records review, and observation the Department has determined that the allegations were Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

This report was review with Jennifer Flores Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2020 and conducted by Evaluator Marybeth Donovan
COMPLAINT CONTROL NUMBER: 26-AS-20200601092250

FACILITY NAME:TWIN LAKES MANORFACILITY NUMBER:
445202247
ADMINISTRATOR:JOSE A. MAGALLANFACILITY TYPE:
740
ADDRESS:777 VOLZ LANETELEPHONE:
(831) 477-1100
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY:12CENSUS: 5DATE:
08/02/2021
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jennifer Flores AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility failed to seek timely medical attention
Staff not meeting residents needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Marybeth Donovan and Christine Dolores conducted an unannounced visit to deliver the findings to the above allegations. LPA met with Jennifer Flores Administrator.

Between 06/24/2020-07/23/2021 a total of four staff were interviewed. 4 out of 4 staff stated staff assist residents with brushing their teeth and offer liquids to hydrate residents throughout the day.

Two staff stated R1’s glucose was not checked, and facility staff was not directed to check R1’s glucose. S1 stated R1’s Physician Visit report dated 02/28/2020 was reviewed and notified the responsible party that the facility cannot assist with glucose testing; however, a plan of care was not discussed with the responsible party on how R1 will have glucose checked.

S1 stated on 5/9/2020 staff notified S1 at approximately 8:00am-9:00am that R1 had a change of condition. Staff called the fire department 30 minutes later. The fire department assessed R1 and requested an ambulance.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20200601092250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: TWIN LAKES MANOR
FACILITY NUMBER: 445202247
VISIT DATE: 08/02/2021
NARRATIVE
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Between 06/24/2020-07/09/2020 a total of five residents were interviewed. 4 out of 5 residents stated staff assist them with brushing their teeth or they brush their teeth independently. Four residents stated they are offered liquids throughout the day for hydration. One resident was not able to answer questions regarding assistance with teeth brushing and liquids being offered.

S1 stated R1’s Physician’s Visit Report dated 22/8/2020 was reviewed and S1 notified the responsible party that the facility cannot assist with glucose testing. R1 was not able to perform own glucose testing. Doctor’s orders dated 2/28/2020 included blood glucose testing daily. Testing was not completed per doctor’s orders.

Medical records indicated on 04/18/2020 and 05/09/2020 R1 was taken to the hospital and lab work indicated elevated glucose levels. Medical records also indicated on 05/09/2020 R1 hospital records noted R1 admitted at 3:11pm for an altered mental status.

Based on interviews and review of documents, the preponderance of evidences standard has been met, therefore the above allegations were found to be SUBSTANTIATED. California Code of Regulations, (Title 22), are being cited on the attached LIC9099D. Failure to correct the deficiencies may result in civil penalties.

This report was reviewed with Jennifer Flores Administrator, and a copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 26-AS-20200601092250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: TWIN LAKES MANOR
FACILITY NUMBER: 445202247
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2021
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care(a)(1) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, ... The licensee shall arrange, or assist in arranging, for medical and dental
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Administrator shall develop a plan describing the facility protocols for observing residents for change in conditions, communication log notes, when to seek medical attention, when to call 911 and to develop care plans to address residents needs as required by doctors' orders. Administrator shall submit plan by POC date.
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care appropriate to the conditions and needs of residents. This requirement was not met as evidence by: facility staff did not seek medical attention for R1’s change of condition until 30 minutes later and facility did not have a care plan for R1's glucose testing which poses an immediate health risk to residents in care.

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Type A
03/10/2022
Section Cited
CCR
87628(a)
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87628 Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing ...and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

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Administrator will review the Regulations on Acceptance and Retention of Residents with Prohibitive, Restricted and Allowable Health Conditions. Administrator will submit written statement of review of the regulations and conduct training with staff on these regulations with emphasis on pre-admission assessments, observation and change and condition as it relates to retention and care needs of residents in care.
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This requirement was not met as evidence by: facility retained resident with a Restricted Health Condition. R1 was unable to perform his/her own glucose testing which poses an immediate health risk to resident in care.


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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.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5