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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201719
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:48:27 PM


Document Has Been Signed on 04/28/2022 02:48 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:TWIN OAKS ASSISTED LIVING CENTERFACILITY NUMBER:
547201719
ADMINISTRATOR:MANDY RANCOURFACILITY TYPE:
740
ADDRESS:999 NORTH M STREETTELEPHONE:
(559) 684-1001
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY:85CENSUS: 50DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mandy Rancour, AdministratorTIME COMPLETED:
03:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced for an Annual Required Inspection. LPA met with Administrator Mandy Rancour. LPA stated the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Facility had no fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trashcans. Hand washing posters were observed by the bathrooms. Bedrooms were checked. The exterior tour was conducted.

LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community. Resident’s files have updated emergency contact information.

Based on today’s inspection, deficiencies were cited in the areas evaluated and listed on the LIC809D according to California Code of Regulations Title 22.

Exit interview was conducted.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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Document Has Been Signed on 04/28/2022 02:48 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: TWIN OAKS ASSISTED LIVING CENTER
FACILITY NUMBER: 547201719

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)


87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed facility hallways 1, 2, and 3 are stained and it also appears to be a tripping hazard. LPA observed Patio exit door does not have a handle in between hallway #2 and #3. LPA observed an unsecured internet cord in hallway #2 outside of the spa room. Based on observations, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2022
Plan of Correction
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Licensee shall submit written plan of correction to CCL to clean and repair the hallway #1, #2 and #3 carpet by Monday, 5/2/22. Licensee will repair the patio exit door and secured internet cord by 05/12/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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