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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547201719
Report Date: 09/27/2022
Date Signed: 10/06/2022 01:34:11 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/04/2022 and conducted by Evaluator Lady Cabrera
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220404093255
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: 59DATE:
09/27/2022
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Mandy Rancour, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident did not received medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) L. Cabrera conducted the subsequent complaint investigation visit to the facility. During the course of this complaint investigation LPA interviewed staff, obtained and reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. LPA reviewed Unusual Incident Reports that Community Care Licensing received on 04/29/2022 and 07/06/2022, indicating the misuse of medications and not administering medications as prescribed.

Based on LPAs observations and interviews which were conducted, and record reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations are being cited on the attached LIC 9099D.
Exit interview conducted and Appeal Rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
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 6
Control Number 24-AS-20220404093255
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2022
Section Cited
CCR
87465(d)(2)
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87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly... (2) The date and time of each contact with the physician, and the physician's directions...
This requirement is not met as evidenced by:
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Licensee will submit written statement of when the facility will provide training to all staff that are involved in passing medications to the residents to CCL by 09/28/2022.
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Based on records review and interviews, the Licensee did not meet the Incidental Medical Care, which poses an Immediate Health, Safety and Personal Rights risks to persons 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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/04/2022 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20220404093255

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: 59DATE:
09/27/2022
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Mandy Rancour, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Unqualified staff dispensing medication
Staff not assisting resident with incontinence needs
Staff do not reposition residents
Staff to not assist residents with their hygiene care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) L. Cabrera conducted the complaint investigation visit to the facility. During this visit LPA delivered investigation findings regarding the above allegations. The Department has investigated the complaint alleging: Unqualified staff dispensing medication, Staff not assisting resident with incontinence needs, Staff do not reposition residents and Staff to not assist residents with their hygiene care.

Per interviews, it was reported that Resident Assistants (RA) were unqualified on administering medications. Per records reviewed, the March 2022 former medication technicians had completed medication training. Per facility staff schedule and interviews, for the overnight shift there is an RA and medication technician. According to the interviews, the medication technicians are responsible for administering medications.

Based on staff, residents, hospice interviews and records reviewed facility staff are assisting with incontinence care, turning and repositioning residents, and assisting residents with their hygiene care for residents on hospice.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
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 6
Control Number 24-AS-20220404093255
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 09/27/2022
NARRATIVE
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Based on the interviews conducted and records reviewed the above allegations are UNSUBSTANTIATED. 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, therefore the allegations are unsubstantiated.

Exit interview conducted and Appeal Rights were provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/04/2022 and conducted by Evaluator Lady Cabrera
COMPLAINT CONTROL NUMBER: 24-AS-20220404093255

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: 59DATE:
09/27/2022
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Mandy Rancour, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not seek medical attention for a resident
Facility AC in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) L. Cabrera conducted the complaint investigation visit to the facility.
During the course of this investigation LPA reviewed facility files relevant to the complaint investigation. It was determined that the above allegation: Staff did not seek medical attention for a resident and Facility AC are disrepair is UNFOUNDED.

Complainant reported R2 heels were “raw” and did not seek medical attention. Per records reviewed and interviews, R2 heels are not raw. R2 continues to be seen by hospice staff.

Based on records reviewed and Administrator interview the facility initiated the dining area air conditioner (AC) to get repaired. Administrator implemented a plan where dinner meals were served in the residents’ private rooms when there was a high temperature. The AC did not affect any of the resident’s private room temperature. LPA observed all AC units in working conditions on today’s date.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 24-AS-20220404093255
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 09/27/2022
NARRATIVE
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This agency has investigated the complaint alleging Staff did not seek medical attention for a resident
and Facility AC in disrepair. We have found that the complaint was unfounded, therefore we have dismissed the complaint. Exit interview was conducted.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 513-9832
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6