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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201719
Report Date: 08/09/2022
Date Signed: 08/09/2022 01:29:57 PM


Document Has Been Signed on 08/09/2022 01:29 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: 58DATE:
08/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Mandy Racour, AdministratorTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced case management visit to the facility. LPA met with Administrator Mandy Rancour and LPA stated the purpose of the visit.

CCL Office received Unusual Incident/Injury Report (SIR) dated 07/18/2022 regarding Resident (R1) to follow-up regarding R1's unwitnessed fall. R1 does not like to be disturbed during his sleep and once staff saw R1’s bump on his left eye staff inquired what happened. Per records reviewed, R1 is independent. R1 was transported to Tulare Hospital and returned the same day with no new orders. LPA interviewed resident.

CCL Office received Unusual Incident/Injury Report (SIR) dated 07/07/2022 regarding Resident (R2) to follow-up regarding R2's health and safety. LPA requested further information.

CCL Office received Unusual Incident/Injury Report (SIR) dated 07/03/2022 regarding Resident (R3) to follow-up regarding health and safety. Per SIR, R3 alleged staff threw the sheet at R3's face. Per facility’s internal investigation, it did not have enough evidence. Administrator reported staff was provided with a verbal warning about resident rights and community rules regarding customer service. Administrator reported staff is no longer working at the facility. LPA interviewed R3 and did not recall the incident. Per records reviewed, Physician's Report it indicates R3 has mild cognitive impairment.

Deficiencies were not cited at this time. LPA provided a copy of this report to the Administrator.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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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