TWIN OAKS MANOR

Official classification

Type B

Official code

87470(c)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews conducted and records reviewed, the facility failed to provide an Infection Control Plan which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Administrator must provide Infection Control Plan by POC due date.

Official classification

Type B

Official code

87470(c)(1)(C)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (C) An Infection Control Training Plan. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews conducted and records reviewed, the facility failed to provide an Infection Control Plan which poses/posed a potential health, safety or personal rights risk to persons in care. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Administrator must provide Infection Control Plan by POC due date.

Official classification

Type B

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews conducted and records reviewed, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Administartor is required to mainatain a fire clearance by POC due date.

Official classification

Type B

Official code

87412(a)(6)(A)

Regulation authority

CCR

What the official deficiency says

(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g). This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews conducted and records reviewed, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Administartor is required to mainatain a fire clearance by POC due date.

Official classification

Type B

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews conducted and records reviewed the licensee has not met certification requirements specified in Section 87406 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Administrator needs to provide a valid Amdministrator certificate by POC due date.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews conducted and records reviewed the licensee has not met certification requirements specified in Section 87406 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Administrator needs to provide a valid Amdministrator certificate by POC due date.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement The licensee did not ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Licensee must provide each clients complete record for licensing agency by POC due date. Additionally Administrator needs to povide all former clients reports to LPA by POC due date.

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews and annual visit administrator failed to provide record is for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Administrator needs to provide record is for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff by POC due date

Official classification

Type B

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs interviews and observations Administrator failed to provide a valid emergency and disaster plan, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Administrator needs to provide a valid emergency and disaster plan by POC due date

Official classification

Type B

Official code

1569.695(a)(1)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs interviews and observations Administrator failed to provide a valid emergency and disaster plan, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Administrator needs to provide a valid emergency and disaster plan by POC due date

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(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 Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above by not being able to produce a current copy of the facility's certificate of liability insurance, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction Licensee reported they will email LPA a current copy of the facility's certificate of liability insurance by close of business on 6/6/2025.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review the licensee did not comply with the section cited above in 1 out of 1 times which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/01/2024 Plan of Correction The Licensee agrees to have S1 to enroll and complete CPR/first aid training and submit proof of completion. Proof of enrollment is to be submitted to the department by 5pm on the due date indicated 6/1/24.

Official classification

Type A

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(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 Based on record review the licensee did not comply with the section cited above in 1 out of 1 times which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/01/2024 Plan of Correction The Licensee agrees to conduct an emergency disaster drill. Proof of the drill is to be submitted to the department by 5pm on the due date indicated 6/1/24.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and records review the licensee did not comply with the section cited above in 2 out of 2 times which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/14/2024 Plan of Correction The licensee agrees to have staff complete and on going dementia training. Proof (sign in sheet, certificate) is to be submitted to the department by 5pm on the due date indicated 6/14/24.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above 18 out of 18 times, as there were 18 expired food items. Observed during LPAs visit which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/14/2024 Plan of Correction The Licensee agrees to check for any additional expired food and discard the items. No POC is due as the 18 item were discarded at the time of LPAs visit.

Official classification

Type B

Official code

87467(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review , the licensee did not comply with the section cited above in 2 out of 2 times which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/14/2024 Plan of Correction The Licensee agrees to complete reappraisals for current residents. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

Official classification

Type A

Official code

1569.269(a)(1)(10)

Regulation authority

HSC

What the official deficiency says

Enumerated Rights; Severability-Residents of residential care facilities for the elderly shall have all of the following rights: To be accorded dignity in their personal relationships with staff, residents, and other persons and to be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. These requirements were not met based upon interviews and a review of records. This was not met as evidenced by - The licensee did not ensure that residents were free from physical abuse on May 5, 2022 S1 hit R1, R2 Licensee and Staff causing several injuries to R1, Licensee and staff. This is an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agrees that the involved staff will no longer be allowed inside the facility. In-service training was conducted by the Licensee regarding resident personal rights. POC cleared.

Deadline recorded: Apr 21, 2023. A deadline is not proof that correction was completed.