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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547201719
Report Date: 03/18/2022
Date Signed: 03/18/2022 02:31:43 PM


Document Has Been Signed on 03/18/2022 02:31 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:MANDY RANCOURFACILITY TYPE:
740
ADDRESS:999 NORTH M STREETTELEPHONE:
(559) 684-1001
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY:85CENSUS: DATE:
03/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Rosanna Renteria, Business Office ManagerTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Lady Cabrera conducted an unannounced case management visit to the facility. Administrator Mandy Rancour was unavailable. LPA introduced herself to Rosanna Renteria, Business Office Manager and stated the purpose of the visit. LPA left a voice message for Administrator and requested a call back.

CCL Office received Unusual Incident/Injury Report (SIR) dated 03/08/2022 regarding Staff was verbally aggressive towards Resident (R1). Per SIR, Administrator and facility staff immediately intervened and removed Staff away from R1 and other residents that were present.

LPA requested R1’s and staff personnel documents. Business Office Manager was able to provide LPA with requested documents. LPA interviewed facility staff and R1.

Follow-up is required once LPA conducts interviews and review records.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
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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