445202247-9-12-2024-26-AS-MTAN-D92RA7-20240912125041

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445202247
Report Date: 09/12/2024
Date Signed: 09/12/2024 12:50:54 PM

Document Has Been Signed on 09/12/2024 12:50 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	TWIN LAKES MANOR		FACILITY NUMBER:	445202247
ADMINISTRATOR:	JENNIFER FLORES		FACILITY TYPE:	740
ADDRESS:	777 VOLZ LANE		TELEPHONE:	(831) 477-1100
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95062
CAPACITY:	12	CENSUS: 8	DATE:	09/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator, Jennifer Flores		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Marcella Tarin, Manuel Monter, and Santino Fortes arrived to conduct a 1 year unannounced annual inspection. LPAs met with Administrator (ADM) Jennifer Flores. The facility serves elderly residents, 60 years and older, and all residents may be non-ambulatory. LPAs toured the facility inside and out with the Administrator to include the living room, dining room, kitchen, resident bedrooms, bathrooms, and backyard. All emergency exits were observed to be clear of obstruction. LPAs toured the kitchen and dining room. Facility has 7 days worth of nonperishable foods and 2 days worth of perishable food supply. Refrigerator temperature maintained at 48 degrees F and freezer temperature maintained at -0 degrees F. LPAs toured 2 out of 2 hallway bathrooms. Hand soap, paper towels and functioning lights in 2 out of 2 bathrooms observed. Water temperature in 2 out of 2 hallway bathrooms measured at 118 degrees F. LPAs observed tags on fire extinguishers with an inspection date of 6/24/2024. ADM tested the carbon monoxide detectors and were observed to be operational. LPAs toured 8 out of 8 resident bedrooms. LPAs observed 7 out of 8 resident bedrooms to have clean bedding, functioning lights, storage space for belongings, a chair and a dresser. At 10:10AM, LPAs toured R1's bedroom and noted a strong malodor. LPAs observed blood on R1's top bed sheet (photograph was taken). ADM states R1 has been scratching herself since admission (10/28/2020). ADM states both R1's Power of Attorney (POA) and physician are aware of the residents behaviors. LPAs advised ADM to remove bloody bedding and replace with clean bedding. LPAs reviewed 4 residents Centrally Stored Medication and Destruction Records (CSMDR). LPAs observed 4 out of 4 CSMDRs are complete with all medications documented. See LIC809C.

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TWIN LAKES MANOR	FACILITY NUMBER: 445202247
	VISIT DATE: 09/12/2024

NARRATIVE

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LPAs reviewed 4 resident records. Based on records reviewed, Resident R1-R4 have a neurocognitive disorder. Based on review of the R1-R4 needs and services plan, the plans have not been updated annually. LPAs requested copies of the Physician's Report and Needs and Service Plan for R1-R4.

LPAs reviewed 4 staff records. LPAs observed 4 out of 4 staff records as complete. 4 out of 4 staff obtained fingerprint clearance, annual training, health screening, TB result, personnel record, and employee rights.

LPAs interviewed 3 staff and 3 residents.

LPAs requested to review facility's disaster drill logs. ADM stated she conducts drills annually, with the last drill conducted on 10/3/2023.

Deficiencies were cited today per California Code of Regulations Title 22. See LIC809-D. This report was reviewed with Administrator Jennifer Flores and a copy of the report and appeals rights were provided.

END OF REPORT

SUPERVISOR'S NAME: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/12/2024 12:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(3)(C)

Personal Accommodations and Services

(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs observed R1's bedroom to have a strong malodor. LPAs observed blood on R1's top bedsheet at 10:10AM which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/19/2024
	Plan of Correction
1 2 3 4	Licensee will submit a written POC stating she will ensure residents have clean linens daily by having staff check residents linen or as needed to ensure that clean linen is in use by residents at all times to CCL via email by POC due date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. LPAs observed the emergency drill log. The last drill was conducted on 10/3/2023. ADM stated she conducts drills annually which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/19/2024
	Plan of Correction
1 2 3 4	Licensee will submit a written POC stating she will conduct emergency drill this week and she will document. Licensee states she will conduct emergency drills quarterly via email to CCL by POC due date.

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: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/12/2024 12:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Based on review R1-R4s physician's report state they have neurocognitive disorder. Based on review of R1-R4 needs and services plan, the plans have not been updated which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/19/2024
	Plan of Correction
1 2 3 4	Licensee states she will submit a written POC stating that she will ensure needs and services plans are completed annually to ensure the resident's dementia care needs are met via email to CCL by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jin Jackie	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marcella Tarin	TELEPHONE: (714) 328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

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