547201719-5-12-2021-24-AS-LCAA-C2XUUA-20210512155313

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 547201719
Report Date: 05/11/2021
Date Signed: 05/12/2021 03:53:15 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 CENTER		FACILITY NUMBER:	547201719
ADMINISTRATOR:	MANDY RANCOUR		FACILITY TYPE:	740
ADDRESS:	999 NORTH M STREET		TELEPHONE:	(559) 684-1001
CITY:	TULARE	STATE: CA	ZIP CODE:	93274
CAPACITY:	85	CENSUS: 40	DATE:	05/11/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Mandy Rancour, Administrator		TIME COMPLETED:	10:28 AM

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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 05/04/2021, 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.

Administrator will provide copies of the internal investigation, Resident's physician report, admission agreement and written statements from staff by 5/12/2021.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021

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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