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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201719
Report Date: 06/23/2023
Date Signed: 06/27/2023 01:26:35 PM


Document Has Been Signed on 06/27/2023 01:26 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:
06/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Mandy RancourTIME COMPLETED:
02:15 PM
NARRATIVE
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On 06/23/23, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required Annual Inspection Visit. LPA was greeted by Administrator, stated the purpose of the visit and was allowed entry into the facility.

LPA toured the facility inside and out with Staff S1 and Administrator. LPA observed the required 7-day supply of non-perishable food and a 2- day supply of fresh perishables. Supplies were observed to be properly stored.

Facility is observed to be free from odor and any passageway obstruction/fire hazards. Facility temperature reads 71 degrees F. LPA observed stained carpets in the dining area and living room area. Torn hallway carpets were observed in 3 out of 3 hallways. LPA observed the required facility postings in a common area for residents.

Common area bathroom water temperature tested at 110 degrees F. Cleaning supplies were observed to be locked in a janitorial closet. Fire Extinguishers throughout the facility were observed with a service date of 03/12/23. Quarterly Emergency Disaster Drill logs were observed for staff. Due to technical difficulties, a sample of resident and staff files will be reviewed at a later date.

Based on LPAs observation, and in accordance with the California Code of Regulations, Title 22, a deficiency is being cited on the attached LIC 809D. If not corrected, this poses a potential Health, Safety or Personal Rights risk to residents in care.

(Continued on 809-C)
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
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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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: 06/23/2023
NARRATIVE
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(Continued from 809)


An exit interview was conducted with Administrator and a plan of correction was reviewed and developed. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 74
Document Has Been Signed on 06/28/2023 01:02 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/28/2023 12:56 PM

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: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303


This requirement is not met as evidenced by: LPA's observation of carpets throughout facility. Brown carpet in common areas (Dining Room, Living Room) is stained (see pictures). Blue hallway carpets in 3 out of 3 hallways are thin, have tears and bubbles.
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2023
Plan of Correction
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Administrator will have brown carpets cleaned in the common areas and will replace the blue carpets that are torn/bubbled in ALL (3 out of 3) facility hallways. Administrator will send pictures evidencing brown carpet cleaned and stains are removed in the common areas, (Dining , Living Room, Gym area), Administrator will replace carpets by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
LIC809 (FAS) - (06/04)
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