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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201719
Report Date: 08/28/2024
Date Signed: 08/28/2024 07:08:46 PM


Document Has Been Signed on 08/28/2024 07:08 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:SHELLHAMER, DAVIDFACILITY TYPE:
740
ADDRESS:999 NORTH M STREETTELEPHONE:
(559) 684-1001
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY:0CENSUS: 49DATE:
08/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, David Shellhamer
Residential Care Coordinator, Wendy Valdez, 		TIME COMPLETED:
03:15 PM
NARRATIVE
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On 08/28/24, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a case management visit based on LPA's observation of records and interviews during a complaint investigation. LPA stated the purpose of the visit and was allowed entry in the facility.

On a previous visit, LPA conducted interviews ,obtained and reviewed facility and resident records. LPA observed Resident R1's physician's report to be outdated, the needs of residents with dementia are not addressed in the facility's plan of operation, on-the-job training requirements for staff who provide direct care to residents with dementia was not observed. R1 was not provided privacy after their death in a common area of the building.

Based on the information received and per California Code of Regulations Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 809D. A copy of this report and appeal rights were provided at the time of visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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 08/28/2024 07:08 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: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2024
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5)Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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An Audit has been conducted that identified all residents that need updated 602's with a dementia diagnosis. Facility has provided LPA with a list of residents with MCI and/or Dementia diagnosis. *** POC Cleared*** RCC will provided LPA with verification all required assessments have been completed by 09/30/24.
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This requirement was not met as evidenced by LPAs observation of R1's most current LIC602 that was dated 2021.
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Type B
09/13/2024
Section Cited
CCR87705(b)(2)

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87705 Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208 Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2)Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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Administrator will send LPA the amneded plan of opertaion to incluide dementia care by POC date.
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This requirement was not met as evidenced by LPAs observation of facility's current plan of operation. There is nothing documented in the current plan of operation addressing the needs of residents with dementia.
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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: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/28/2024 07:08 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: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2024
Section Cited
CCR
87411(d)(3)(A)

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87411 Personnel Requirements - General
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance:(A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living;


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Facility has scheduled an all staff training for 09/11/24 and will send LPA proof of sign in sheets.
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This requirement was not met as evidenced by LPAs records review and interview with Administrator. Staff have not received training in dementia care.
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Type B
09/06/2024
Section Cited
CCR87468.1(a)(1)

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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons.


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Administrator will conduct an inservice training on personal rights and dementia behaviors by POC date.
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This requirement was not met as evidenced by LPAs records review and interviews, R1 was not provided privacy after their death in a common area of the building.
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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: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3