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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

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

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2024 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20240522153839
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
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:David Shellhamer, Administrator
Wendy Valdez, Residential Care Coordinator 		TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not ensure care and supervision was provided to resident in care
Staff did not ensure reporting requirements were followed
INVESTIGATION FINDINGS:
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On 08/28/24, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above allegations. LPA was greeted by Administrator and Residential Care Coordinator, stated the purpose of the visit and was allowed entry into the facility.

During the investigation, LPA conducted interviews and records review. Based on the information received, and Per California Code of Regulations, Title 22, Division 6, Chapter 8, the preponderance of evidence standard has been met, therefore, the above allegations are found to be Substantiated. Deficiencies are being cited on the attached 9099-D.

An exit interview was conducted with Administrator. A plan of correction was developed by Administrator and reviewed with LPA. A copy of this report and appeal rights were discussed and provided at the time of the visit.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
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Control Number 24-AS-20240522153839
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
87465(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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All residents MARS and CSMDR have been verified and completed. RCC will send a plan on the facilities new policy and procedures for medications by POC date.
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This requirement was not met as evidenced by LPAs records review and interviews. The facility was unable to provide Resident R1''s May 2024 Medication Administration Record (MAR) or Centrally Stored Medication Destruction Record (CSMDR) evidencing medications were given to R1.
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Type B
09/06/2024
Section Cited
CCR
87211(a)(1)(A)
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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... of any of the events specified...(A)Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.
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Administrator / RCC will send verifIcation that Reporting requirements were reviewed and understood by POC date.
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This requirement was not met as evidenced by LPAs records review and interviews. Facility did not provide responsible party a written death report.
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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
LIC9099 (FAS) - (06/04)
Page: 2 of 2