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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201719
Report Date: 12/14/2021
Date Signed: 12/17/2021 10:04:51 AM

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: 48DATE:
12/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Mandy Racour, AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced case management visit to the facility. LPA met with Administrator Mandy Rancour and stated the purpose of the visit.

The purpose of the case management visit is to respond to an incident report that was submitted to CCL Office incident occurred on 05/02/2021 and to discuss information obtained from the initial visit conducted on 05/11/2021. Incident is regarding Resident (R1) alleging Staff (S1) spraying her in the face with water while showering. Administrator conducted an internal investigation, which concluded that Staff (S1) and another staff assisted R1 to prepare for a shower. Staff denied spraying R1 and reported they were outside the bathroom to assist R1 if needed. LPA introduced herself to R1 and stated the purpose of the visit. R1 refused to meet with LPA.

On 09/07/2021, CCL received Unusual Incident/Injury Report regarding R2 and R3 involved in physical altercation. R3 punched his roommate R2 in the face. The residents were immediately separated, and Tulare Police Department was contacted. Staff immediately assessed R2. R2 was relocated to another room in the facility. No follow-up needed. Administrator reported there has been no other issues between R2 and R3.

On 11/10/2021, CCL received Unusual Incident/Injury Report regarding R4 going absent without leave (AWOL) while staff followed R4 to her old house. Staff notified R4’s family member and met them at the house. Per Physician’s report dated 02/05/2021, R4 has mild cognitive impairment and is able to leave facility unassisted and to have family present. No follow-up needed.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
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: 12/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2021
Section Cited

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87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication... (2)The date and time of each contact with the physician...

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: 12/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 12/14/2021
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On 11/29/2021, CCL received Unusual Incident/Injury Report occurred on 11/26/2021 and 11/27/2021 regarding medication errors for residents (R5, R6, R7 and R8). Staff (S2) did not administer the 8p.m. medications to R5, R6, R7, and R8 on 11/26/2021 and on 11/27/2021. All resident’s doctors and responsible party were notified. Residents were placed on 72-hour checks for any side effects. S2 was removed from medication technician position.

Deficiencies are 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: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
LIC809 (FAS) - (06/04)
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