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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201719
Report Date: 07/10/2023
Date Signed: 07/10/2023 08:38:15 PM


Document Has Been Signed on 07/10/2023 08:38 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: 55DATE:
07/10/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Mandy RancourTIME COMPLETED:
08:00 PM
NARRATIVE
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On 07/10/2023, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct an annual continuation from 06/27/23. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility.

LPA completed a tour of all resident rooms with Administrator. On 06/27/23, LPA observed 12 out of 77 rooms. Of those 12 rooms, 6 out of 12 needs carpets replaced and 2 out of 3 glass panels, on the front right door, are be broken and in need of replacement. Front doors are heavy and hard to open.

LPA conducted records review evidencing Grand Oaks Assisted Living, LLC is one of several business' found to be operating on the above licensed premises. Plan of operation for Twin Oaks Assisted Living was unavailable. Records review show Twin Oaks Assisted Living is operating under a new business name of "Grand Oaks Assisted Living", and licensee has not submitted the required notifications and/or application for license under such name.

LPA requested the following updated forms be submitted to the Fresno CCL office by 07/19/2023: Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC 610ES), and a current list of residents names who are receiving Hospice Care and/or Home Health Care services.

(continued on LIC 809-C)
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


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
VISIT DATE: 07/10/2023
NARRATIVE
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(Continued from 809) .

Based on today's inspection, inspection of 06/27/23, and based on LPA's observations and records review the following deficiencies are being cited on the attached 809D. A civil penalty in the amount of $500 is hereby assessed. If not corrected, the violation will have a direct and immediate risk to health safety and personal rights to residents in care.

Exit interview conducted and plans of correction were reviewed and developed. A copy of this report and appeal rights were discussed and provided to Administrator, Mandy Rancour, whose signature on this form confirmed receipt of this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/10/2023 08:38 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: 07/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2023
Section Cited
CCR
87202(a)(2)

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87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons (2) Bedridden persons
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Administrator will submit the LIC200, LIC9054, LIC 999, LIC 610E requesting a bedridden fire clearance by POC date.
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This requirement was not met as evidenced by LPAs observation of Resident R6 and LPAs interview with Resident R8. If not corrected, the violation will have a direct and immediate risk to health safety and personal rights to residents in care.*Civil penalty assessed*
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Type B
07/21/2023
Section Cited
CCR87633(b)(6)(B)

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87633 Hospice Care of Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:(6)Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee’s responsibilities for implementation of the hospice care plan.(B) The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins.
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Administrator will submit Hospice Care Plans for 8 out of 8 residents in care. Proof of training will be submitted to CCL by POC evidencing staff training has been completed by Hospice, per the individual care plans.
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This requirement was not met as evidenced by LPAS observation of 2 out of 2 care plans reviewed. No training was documented as completed prior to retaining residents on Hospice. This poses a potential risk to residents 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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 07/10/2023 08:38 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: 07/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/17/2023
Section Cited
HSC
1569.695(a)(7)(A)

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§1569.695
Emergency Plans (a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to...:
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Administrator will provide a disaster plan includes provisions of power for 72 hours should an emergency be declared.
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(7) Procedures that address, but are not limited to, all of the following: (A) Provision of emergency power that could include identification of suppliers of backup generators. If a permanently installed generator is used, the plan shall include its location and a description of how it will be used. If a portable generator is used, the manufacturer’s operating instructions shall be followed. This requirement was not met as evidenced by LPA's records review, there is not a disaster plan on file that includes provisions of power for 72 hours should an emergency be declared.
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Type B
07/21/2023
Section Cited
CCR87208(a)(1)

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87208 Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (1) Statement of purposes and program goals.
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Licensee will submit a plan of operation by POC date.
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This requirement was not met as evidenced by LPA's records review, facility was unable to provide a current plan of operation.
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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: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 07/10/2023 08:38 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: 07/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2023
Section Cited
HSC
1569.191(e)

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§1569.191 Sale of licensed facility; resulting issuance of new license; procedure
(e), the property and business shall not be transferred until the buyer qualifies for a license or provisional license within the appropriate provisions of this chapter.
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Licensee will submit application to CCL by POC date.
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This requirement was not met as evidenced by LPA's observation of Secretary of State records showing this facility location operating as "Grand Oaks Assisted Living Facility" Licensee has not notified CCL or submitted an application for a new license. If not corrected, this poses an immediate risk to the Health, safety and/or personal rights to residents 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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
LIC809 (FAS) - (06/04)
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