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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601155
Report Date: 06/05/2025
Date Signed: 06/05/2025 01:10:07 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/29/2025 and conducted by Evaluator Janette Romero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250529081241
FACILITY NAME:TWIN OAKS GARDEN IIFACILITY NUMBER:
374601155
ADMINISTRATOR:SNEZANA LUKICFACILITY TYPE:
740
ADDRESS:1961 EDWIN LANETELEPHONE:
(760) 471-8704
CITY:SAN MARCOSSTATE: CAZIP CODE:
92069
CAPACITY:6CENSUS: 6DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
11:14 AM
MET WITH:Administrator, Tanja Lukic TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff are restraining a resident
Facility is exceeding hospice waiver capacity
INVESTIGATION FINDINGS:
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On 6/5/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility to investigate the allegations listed above. LPA met with Tanja Lukic who identified themselves as one of the administrators. Lukic was informed of the purpose of the visit. During today's visit, LPA toured the facility, conducted interviews, and obtained copies of pertinent records.

Regarding the allegation, "Staff are restraining a resident" it was alleged staff tied Resident 1 (R1) to a chair in their room by wrapping a fleece blanket around R1 and the chair R1 sat in. It was further alleged R1 was observed sitting on a cushion that is used to restrain residents. LPA toured the facility and did not observe R1 with a blanket or other object tying them to their wheelchair. LPA observed R1 sitting on a cushion in their wheelchair. R1 was unqualified for an interview as LPA determined them to be an unqualified historian. As a result, LPA conducted an interview with R1's responsible person who reported the following information. R1's primary care physician provided a prescription for the soft blanket tied in front to assist with postural support and avoid them from slipping out of their wheelchair. When R1 goes into the community without the cushion, R1's responsible person has noticed R1 will slip out of their wheelchair.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20250529081241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: TWIN OAKS GARDEN II
FACILITY NUMBER: 374601155
VISIT DATE: 06/05/2025
NARRATIVE
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R1's friends/family visit R1 at the facility approximately three (3) times per week and no one has reported observations of R1 being restrained in the facility. Friend/family visits are unannounced and R1 is always observed well kept with no foul odors, eating well, and with clean bedding. R1's responsible person did not express any issues or concerns with the care and supervision R1 receives in the facility. LPA reviewed a prescription order for R1 dated 1/21/2025 stating R1 "needs a soft blanket tied in front for postural support and safety". Lukic was interviewed and reported the soft blanket tied in the front is occasionally placed on R1 for better support and to prevent them from falling. Lukic added R1 has the ability to untie the soft blanket on their own and staff was trained on how to properly tie the soft blanket. One (1) staff was interviewed and corroborated the information provided by Lukic.

Regarding the allegation, "Facility is exceeding hospice waiver capacity" it was alleged the facility is licensed to house two (2) hospice residents and currently has four (4) residents on hospice. LPA conducted a record review which noted on 3/1/2024, the facility was granted a hospice waiver increase for a total of three (3) residents. Lukic was interviewed and reported Resident 2 (R2), Resident 3 (R3), Resident 4 (R4), and Resident 5 (R5) are currently receiving hospice services at the facility. A review of admission agreements and hospice care plans note R2, R3, and R4 were admitted to the facility sometime in 2023 or 2024 and all three (3) residents were admitted to hospice in 2024. A review of R5's admission agreement and hospice care plan indicates R5 was admitted to the facility on 5/3/2021 and to hospice on 5/23/2025. On 5/22/2025, LPA received an email from Licensee, Snezana Lukic with a hospice waiver increase request to house four (4) terminally ill residents at a time. Lukic reported the facility has not accepted any new residents who were on hospice upon admission to the facility and licensee submitted an hospice waiver increase request as soon as they learned R5 would be admitted to hospice. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was reviewed and provided to Lukic along with a Confidential Names list (LIC 811).
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2