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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201719
Report Date: 02/09/2023
Date Signed: 02/10/2023 02:47:56 PM


Document Has Been Signed on 02/10/2023 02:47 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: 60DATE:
02/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator Mandy Rancour, via telephone TIME COMPLETED:
06:15 PM
NARRATIVE
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On 01/09/23, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a complaint investigation. During the course of interviews and records review, it was found that Resident R1 sustained a fall, hitting their head and the facility did not call 911 or seek Emergency Medical Services for R1. Facility called Hospice to assess, however, the injury R1 sustained, is outside the diagnosis and/or care plan for Hospice Services. Hospice does not conduct the diagnostic testing for head injuries.

LPA interviewed and observed Resident R1 to have a scab front a cut on their forehead and a yellow bruise on the right side of the face. R1 stated the have been experiencing alot of pain in their left leg and stated they have been experiencing head aches and feeling worse since the fall. R1 stated they were not seen by a medical doctor. Facility incident report states they called Hospice to evaluate resident after fall.

Based on today’s visit, a deficiency is being cited, per California Code of Regulations, Title 22, Division 6, Chapter 8 on the attached 809D. An Immediate Civil Penalty is being assessed in the amount of $500 in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted with Administrator via telephone and a copy of this report and appeal rights were discussed. LPA provided a copy of this report to the office manager, on behalf of the Administrator. Administrator authorized, via telephone, for office manager to sign report. A plan of correction was developed by Administrator and reviewed with LPA. Administrator will send POC by 02/10/23.


SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
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 02/10/2023 02:47 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: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/10/2023
Section Cited

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87465 Incidental Medical and Dental Care
(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...This requirement was not met as evidenced by LPA's interview with R1 and observation of facility records. Facility did not seek emergency medical attention for R1 after they fell and hit their head that caused a "goose egg" and swelling.
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Facility will seek Medical attention for Resident R1 today. Administrator will provide proof of discharge papers that R1 has been seen and evaluated by a Physician by POC date of 02/10/23.
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If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of clients in care. Immediate Civil Penalty in the amount of $500 is being assessed.
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Administrator will submit proof that an in-service was conducted with all care staff regarding falls and Hospice services by POC date.

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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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
LIC809 (FAS) - (06/04)
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