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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201719
Report Date: 06/12/2024
Date Signed: 06/14/2024 11:12:55 AM


Document Has Been Signed on 06/14/2024 11:12 AM - 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:SHELLHAMER, DAVIDFACILITY TYPE:
740
ADDRESS:999 NORTH M STREETTELEPHONE:
(559) 684-1001
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY:85CENSUS: 43DATE:
06/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:David Shellhamer, Administrator TIME COMPLETED:
12:23 PM
NARRATIVE
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On 06/12/24, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct a case management visit based on observations during facility file reviews. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility.

On 03/07/24 and 04/17/24, Resident R1 eloped from the facility and was located and returned by local police on both occasions. R1 has had a diagnosis of dementia. LPA did not observe a reappraisal done after the first elopement on 03/09/24, however, one was completed after the 04/19/24 incident. The facility issued a 30 day eviction letter stating they cannot meet the needs of the R1. The eviction letter issued was unlawful and did include the required information. An immediate civil penalty in the amount of $500 is hereby assessed for the absence of supervision.

On 03/20/24 and 04/28/24, Death Report's were received for Resident R2 and Resident R3. LPA reviewed file and observed R3 and R4 were hospitalized prior to their death. No incident reports were submitted for hospitalization's.

The following medication errors have been observed:

On 04/16/24, facility reported Resident R4 was given a duplicate dose of medication. On 4/26/24, facility reported Resident R4 was out of 2 medications.

On 05/16/24, facility self reported Resident R5 was given a PRN medication, per family request, resulting in a duplicate dose. ,

On 05/19/24, facility self reported Resident R6 had been without cholesterol medication for 5 days. Medication had been received but was not logged or dispersed per physicians orders.

Staff S1 was observed to have been working without fingerprint clearance. S1 has been taken off the schedule and will not be working until a Live Scan is done and a fingerprint clearances and criminal records have been approved. An immediate civil penalty in the amount of $500 is hereby assessed.

Based on today’s visit and per California Code of Regulations, Title 22, Division 6, deficiencies are being cited on the attached 809D. Civil Penalties in the amount of $1000 are hereby assessed. If not corrected, this poses an immediate risk to the health safety and/or personal rights of resident's in care.



An exit interview was conducted with Administrator and plans of corrections were developed with POC dates of 06/13/24 and 06/21/24. Copies of these reports and appeals rights will be delivered via email with a read receipt confirmation.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
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 3


Document Has Been Signed on 06/14/2024 11:12 AM - 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: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/13/2024
Section Cited
HSC
1569.49(c)(3)

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§1569.49 Civil penalties;
(c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations:
(3) Absence of supervision as required by statute or regulation.
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Administrator will review all resident files and determine which residents in care have a diagnosis of dementia and/or those showing signs of dementia. Administrator will provide LPA with a list of names by POC date of 06/13/24. Administrator will also include and provide the dates of the most recent physician's report (LIC602) (for the resident's with a diagnosis of dementia and/or those showing signs of dementia by POC date of 06/21/24.
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This requirement was not met as evidenced by records review of self reported incident and police records stating R1 has eloped from the facility on more than one occasion. R1 has a diagnosis of dementia and cannot leave the facility unsupervised.
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Type A
06/21/2024
Section Cited
CCR1569.17(b)1)(1A)

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(b) In addition to the applicant, the provisions of this section shall apply to criminal convictions of the following persons:
(1)(A) Adults responsible for administration or direct supervision of staff.


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S1 has been taken off the schedule and will not be working until a Live Scan is done and a fingerprint clearances and criminal records have been approved. Administrator will review staff schedule and facility roster to ensure all staff are cleared. Administrator will send current roster and staff schedule by POC date of 06/21/24. An immediate civil penalty in the amount of $500 is hereby assessed.
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This requirement was not met as evidenced by: Based on records review S1 was not finger print cleared to work in the facility which poses an immediate risk to Health and Safety of resident in care. Immediate Civil Penalty being assessed in the amount of $500.00.
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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: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/14/2024 11:12 AM - 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: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2024
Section Cited
CCR
87224(d)(1)(C)

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87224 Eviction Procedures
(d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.(1) The notice to quit shall include the following information: (C) A statement informing residents of their right to file a complaint with the licensing agency, as specified in Section 87468, subsection (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business...

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Administrator will provide LPA with a revised letter to include all required information by POC date of 06/21/24.
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This requirement was not met as evidenced by LPAs observation of eviction letter provided to the family of R1. Eviction letter did not include the required language.
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Type B
06/21/2024
Section Cited
CCR87465(a)(1)

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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Administrator will provide LPA with proof of training for medication refill procedures , Centrally Stored Medication Destruction Record (CSMDR) and logging medication.
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This requirement was not met as evidenced by LPAs observation of self reported incident reports.
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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: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3