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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201719
Report Date: 05/11/2021
Date Signed: 05/12/2021 03:43:21 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: 40DATE:
05/11/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Mandy Rancor, AdministratorTIME COMPLETED:
10:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Lady Cabrera conducted a subsequent Case Management visit to discuss information obtained from the initial visit conducted on 04/21/2021. Case Management was conducted via telephone due to COVID-19 and pre-cautionary measures. LPA spoke with Mandy Rancour, Administrator.

During the investigation, Resident (R1) was prescribed to receive the medication every 3 hours and as needed. The resident received the medication 2 times on 4/2/21, 3 times on 4/3/21 and 3 times on 4/4/21 instead of every 3 hours. The staff were written up and retrained on medication management immediately on 4/26/21.

Based on the LPAs interview and records review, the Licensee did not meet California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87465(c)(2) Incidental Medical and Dental Care. Deficiency is being cited on the attached LIC 809-D.

Exit interview was conducted. A copy of this report, LIC809, LIC809-D and appeal rights were provided. The Licensee’s signature on this form acknowledges receipt of these documents.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (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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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: 05/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2021
Section Cited

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87465 Incidental Medical...(c)...physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...(2)Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
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Based on records review and interviews, the Licensee did not meet the Incidental Medical Care, which poses an Immediate Health, Safety and Personal Rights risks to persons in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2021
LIC809 (FAS) - (06/04)
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