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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201719
Report Date: 04/30/2021
Date Signed: 04/30/2021 04:51:05 PM

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: DATE:
04/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Mandy Rancour, AdministratorTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Lady Cabrera contacted Mandy Rancour, Administrator by phone due to COVID-19 and pre-cautionary measures.

On 4/23/2021, Community Care Licensing received the Unusual Incident/Injury Report. The purpose of the phone call is to follow-up on the health and safety check of the resident and to obtain additional information regarding medication error that occurred on 4/22/2021. Administrator reported Staff was retrained on Medication Management on 4/26/2021.

LPA requested the following documents and records:

1. Resident’s Admission Agreement

2. Physician's Report (LIC602A)

3. April 2021 Centrally Stored Medication and Destruction Record and Medication Administration (MAR) form

The above documents shall be submitted to CCLD by 5/4/2021.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
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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