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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607906
Report Date: 09/06/2024
Date Signed: 09/09/2024 12:06:58 PM

Document Has Been Signed on 09/09/2024 12:06 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:TWIN HOMECARE - AFACILITY NUMBER:
197607906
ADMINISTRATOR/
DIRECTOR:		NAPOLEON GARCIAFACILITY TYPE:
740
ADDRESS:2104 W. 242ND STREETTELEPHONE:
(424) 263-4779
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 6CENSUS: 6DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Angela MacasiebTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 09/06/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Caregiver, Angela Macasieb, and the purpose of today’s visit was explained. We were later joined by Administrator Designee, Charesa Reyes. The facility is licensed to serve six (6) non-ambulatory residents, of which six (6) may be bedridden and may retain six (6) hospice residents, over the age of 59. Currently residing in the facility are six (6) residents.
Physical Plant/Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: 6 resident bedrooms, 3 resident bathrooms, staff room, staff bathroom, living room, dining area, sitting room, kitchen, garage, laundry room, supply room, and backyard patio area. The backyard has a table with umbrella and chairs. LPA observed all walkways around the facility to be clean, clear, and free of obstructions, debris, or hazards. LPA did not observe any bodies of water on the premises.
Bedrooms LPA inspected all resident rooms and observed the walls and floors to be in good repair. Beds and bedding were in good condition. LPA observed all resident rooms had the required furniture including a bed, dresser, nightstand,
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TWIN HOMECARE - A
FACILITY NUMBER: 197607906
VISIT DATE: 09/06/2024
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storage space for personal belonging, and ample lighting. LPA observed all beds
had the required linens including a mattress cover, fitted sheet, blanket, comforter, and pillows. LPA observed an ample supply of bed linens, and comforters in good repair stored in the cabinet in the hallway.
Bathrooms LPA inspected the facility bathrooms and found them to be within Title 22 regulations. All bathrooms were observed clean and operational. LPA observed storage area for personal hygiene products for each individual resident in the storage room in the hallway. LPA observed an ample supply of towels and personal hygiene products available for residents. All showers had a nonskid mat, secured safety handrails, and a shower chair. The water temperature measured 119.1-degrees, 118.4-degrees, 117.9-degrees and 117.4-degrees Fahrenheit.
Kitchen LPA inspected the kitchen and observed it to be clean and sanitary. LPA observed all appliances to be operable and in good repair. LPA observed an ample supply of dishware, cookware, and cutleries. LPA observed a 2-day supply of perishable foods and a 7-day supply of non-perishable foods properly stored and labeled. The water temperature measured 118.1-degrees Fahrenheit. All sharps are secured in a locked drawer in the kitchen and are inaccessible to residents. All cleaning supplies are secured in a locked cabinet under the kitchen sink and in locked cabinets in the laundry room and are inaccessible to clients.
Common Rooms LPA observed the facility to be appropriately furnished during the time of visit. The facility has a sitting room with two (2) couches to accommodate all residents. LPA observed the living room to have recliners to accommodate all
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TWIN HOMECARE - A
FACILITY NUMBER: 197607906
VISIT DATE: 09/06/2024
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residents. LPA observed an ample supply of games, activities, reading material and puzzles available. LPA observed two (2) fireplaces screened and inaccessible to residents. The dining room table is large enough to accommodate residents for meals. LPA observed all walkways and hallways to be clean, clear, and free of hazards and obstructions. All rooms were observed with ample lighting. The facility was kept at a comfortable temperature of 76.3-degrees Fahrenheit.
Safety LPA observed a fully charged fire extinguisher, located in the kitchen. All smoke and carbon monoxide detectors are operable. The last emergency drill was conducted on 09/01/24. LPA inspected the First Aid Kit and observed it had the required items. The facility sketch is posted in the hallway near the entrance of the facility. The facility’s Emergency and Disaster Plan was observed posted. LPA observed all required documents posted in the facility. The facility has a working landline telephone. There are no firearms are ammunition stored at the facility.
Medication LPA observed all Centrally Stored Medications secured in a locked cabinet, in the kitchen, and are inaccessible to residents. All medications were observed in their original packaging. LPA reviewed the medications and Medication Administration Record (MAR)for the three (3) residents. Three (3) out of three (3) resident’s MARs and medication are consistent with properly documented records.
Infection Control Upon entry, LPA observed a sanitizing station and visitor sign-in log. LPA observed on the table there is hand sanitizer, gloves, and masks available. LPA observed all required Infection Control signs posted in the facility. LPA observed a 30-day supply of Personal Protective Equipment (PPE) stored in the garage.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TWIN HOMECARE - A
FACILITY NUMBER: 197607906
VISIT DATE: 09/06/2024
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File Review LPA reviewed the files for the four (4) residents and observed they had the required documents. LPA reviewed the administrator and three (3) staff files and found they contained the required documents, certification, and training. The administrator’s Administrator Certificate is valid till 11/20/24. LPA reviewed the liability insurance through ACORD valid till 10/28/24. During file review, LPA observed licensing fees are current.

During today’s LPA did not observe or cite any deficiencies.

An exit interview was conducted with Administrator Designee, Charesa Reyes , and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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