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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530062
Report Date: 01/24/2025
Date Signed: 01/24/2025 06:18:01 PM

Document Has Been Signed on 01/24/2025 06:18 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TWIN HEARTS SENIOR CARE IIFACILITY NUMBER:
335530062
ADMINISTRATOR/
DIRECTOR:		MANGENTE, KRISTINEFACILITY TYPE:
740
ADDRESS:342 E OLIVE STREETTELEPHONE:
(951) 373-9122
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 6CENSUS: 6DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Administrator - Kristine Mangente TIME VISIT/
INSPECTION COMPLETED:
06:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with staff Juwita Pratiwi Elisabeth and was granted entry to the facility. Licensed capacity is (6) current census (6). LPA was accompanied by Licensee/Administrator Kristine Mangente to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to resident in care. There was a designated space for resident/staff files. LPA observed a swimming pool in backyard, gate was safely secured by locked iron a gate around the perimeter.

During facility tour, LPA observed a bed mattress inside R1 closet. Licensee confirmed staff sleep inside resident closet to. LPA requested mattress to be removed. In addition, LPA Rico observed 3 out of the 6 residents had full rails and they are not in hospice.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

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SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 01/24/2025 06:18 PM - It Cannot Be Edited


Created By: Mary Rico On 01/24/2025 at 05:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE II
FACILITY NUMBER: 335530062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by S1 and S2 criminal record clearance not transfer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
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Licensee stated they will submit proof of clearance transfer request to LPA Rico.
Type A
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above but not having (6) out of the (6) residents PRN medication resposne documented which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
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Licensee stated they will train their staff, and will provide an updated PRN MAR. A copy will provided to LPA Rico.
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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/24/2025 06:18 PM - It Cannot Be Edited


Created By: Mary Rico On 01/24/2025 at 05:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE II
FACILITY NUMBER: 335530062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of the 6 residents had full bedrails which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
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Licensee stated the facility will remove bedrails and will train staff on the regualtion cited aboved. LPA Rico will be given a copy of training, and proof of removal.
Type A
Section Cited
CCR
87307(a)
87307(a) Personal Accomodation and Services

(a) Living accomdation and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the resident, staff and others who may reside in the facility

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by having S1 sleep in R1's master closet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
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Licensee stated they will remove the mattress and will train staff on the regulation cited above. A copy will be provided to LPA Rico.
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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/24/2025 06:18 PM - It Cannot Be Edited


Created By: Mary Rico On 01/24/2025 at 05:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TWIN HEARTS SENIOR CARE II
FACILITY NUMBER: 335530062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee stated they will conduct an emergency drill and will provided a copy to LPA Rico.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: TWIN HEARTS SENIOR CARE II
FACILITY NUMBER: 335530062
VISIT DATE: 01/24/2025
NARRATIVE
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Record Review: LPA reviewed (6) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (6) resident medications. During medication audit, LPA Rico observed the facility did not have (6) resident’s PRN response documented and maintained in the resident's MAR. Licensee stated the facility does not have hospice residents. LPA also reviewed (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed the facility did not have S1 and S2 associated to the facility. Lastly, the facility did not conduct an emergency drill for over six months.

Based on the observations made during today’s visit, (5) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. The facility was also issued a Civil Penalty in an amount of $1,000. An exit interview was conducted, and this report (LIC809(LIC809D)(LIC421BG) was discussed and provided to Administrator Kristine Mangente. Along with a copy of Appeal Rights

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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