Twin Oaks Garden

Allegation investigated: Staff leaves residents unattended

On 6/5/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility to investigate the allegation 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 leaves residents unattended" it was alleged the facility is made up of two separate buildings and there is only one (1) staff providing care to the residents. It was further alleged when the staff leaves one (1) building to go to the next building, residents in the remaining building are left unattended. LPA reviewed the facility sketch which notes the facility is made of the "main house" and "house addition". LPA knocked on the door of the main house and was greeted by Lukic. LPA toured the facility with Lukic and observed Caregiver, Graciela Arreola and four (4) residents present in the main house and Resident 1 (R1) in their bedroom located in the house addition. Lukic was interviewed and reported the following information. The facility encourages the residents residing in the house addition to socialize and join the residents in the main house. Usually, all five (5) residents enjoy watching television and socializing in the main house. However, R1 has been battling a cough recently and has chosen to remain in their bedroom until they feel better. Unsubstantiated Caregiver Arreola was interviewed and reported they go back and forth between both buildings to check on R1 every thirty minutes. LPA reviewed R1's physician's report dated 2/28/2025 noting R1 is ambulatory, able to communicate their needs, administer their own oxygen and store their own medications, and is not confused/disoriented. R1 was interviewed and reported two days ago, they pressed their pendant due to experiencing a severe cough and four (4) staff immediately responded to their bedroom and provided assistance. R1 reported staff supervise them throughout the day and staff has immediately responded every time they have pressed their pendant. LPA observed R1 press their pendant and heard a signal transmitted to a receiver/pager located in the kitchen, which is reportedly used to alert staff that R1 requires assistance. LPA reviewed an Unusual Incident/Injury Report noting on 6/3/2025, R1 experienced shortness of breath and staff responded and monitored R1 throughout the night. LPA attempted to conduct an interview with two (2) additional residents in the home who were unavailable at the time of the attempt. LPA also made several unsuccessful attempts to make contact with the reporting party to obtain additional details regarding the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is 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).the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 18-AS-20250529101735

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Licensee Snezana Lukic who was informed of the purpose for the visit. At the time of the visit there was two (2) staff and six (6) residents present. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. LPA observed outdoor furniture and shaded area for clients. Detergents, cleaning solutions, and sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide was operational. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA reviewed staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training. Three (3) resident files were reviewed and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and updated Physician's Report. The listed administrator possesses a current administrator's certificate that expires in 2025. Resident medication was centrally stored and locked in a medication cabinet located in the kitchen. LPA reviewed medications prescribed to residents and found all medication with required labeling found to be in place. LPA reviewed the facility's emergency and disaster plan and infection control plan. Facility conducts quarterly fire drills with the last fire drill being conducted on 08/21/2024. All facility exits were clear from obstructions. LPA observed emergency supplies, charged fire extinguishers, and first aid kit with all required items. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Licensee Snezana Lukic.the state’s words, verbatim · CDSS document, Oct 10, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility to conduct an annual licensing inspection. LPA met with Snezana Lukic, Administrator, and discussed the purpose of the visit. The facility is licensed to serve six (6) elderly residents, all of whom may be non-ambulatory. A Hospice waiver is approved for three (3) residents. A tour of the facility was conducted inside and out. At the time of visit, there were five (5) residents home and one (1) staff was available. The facility consist of two (2) housing structures that contain three (3) bedrooms and one and one half (1-1/2) bathrooms in the main house, and a three (3) bedrooms and two and one half (2-1/2) bathroom in the second house. The laundry room is also located in the second structure. During the tour the following was observed: Resident bedrooms had the required furnishings and were observed to be in good condition. Bathrooms had required signage, hand rails, non-slip mats. Night-lights were observed in the hallways. Fixtures and furniture for an operational facility are present and in good repair. All passageways were free of obstructions, charged fire extinguishers and the fire alarm system was operable, medications are kept centralized and locked, hazardous items are kept inaccessible clients. Hot water was tested at 114 degrees Fahrenheit. Backyard area is free from obstructions. Kitchen/Food Service: LPA observed the entire kitchen, food is stored properly and dishes are clean and in good condition. There is a sufficient supply of perishable and non-perishable foods. Area was observed to be clean and functional. Care & Supervision: Facility has sufficient care staff employed. Administration: Emergency exiting plans, telephone numbers and Ombudsman information and other required signage are posted throughout the facility. Drills are conducted quarterly. The last drill was conducted on 10/1/2023. Record Review and Client/Staff Files: LPA reviewed current staff and all staff have Criminal Background Clearance, current CPR/First Aid certification, and trainings are current. Resident records were reviewed and contained required documents. All resident documents were current and up to date. Medication Review: LPA reviewed medication and medication appears to be dispensed according to Physicians orders. No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time. A copy of this report was provided to Administrator, Snezana Lukic.the state’s words, verbatim · CDSS document, Oct 9, 2023