Twin Cedars Youth & Family Services

Deficiency cited, severity D, re-licensure survey

Based on physical plant inspection and staff interview, the facility failed to ensure that all walls were in good repair. Findings include: A physical plant inspection conducted on April 1, 2026, at approximately 10:40 a.m., revealed room #5's lavatory in Cottage #1 had a detached ceiling fixture (photo #13). A physical plant inspection conducted on April 1, 2026, at approximately 11:00 a.m., revealed room #7's lavatory in Cottage #2 had a dark substance on the shower wall that appeared to be mold (photo #50). A physical plant inspection conducted on April 1, 2026, at approximately 11:05 a.m., revealed room #8's lavatory in Cottage #2 had a dark substance on the shower wall that appeared to be mold (photo #53 & #54). During an exit conference on April 2, 2026, at 2:30 p.m. with Staff D, Staff F, Staff G, Staff H, Staff I, and Staff F indicated that Staff D did not locate the facility’s work order for Kemper cottage repairs. Staff F acknowledge the findings.

Deficiency cited, severity B, foster, re-licensure survey

Based on record review and staff interview, the facility failed to document a complete Individual Service Plan (ISP) in two of three foster child records reviewed. Findings include: A review on 05/01/2025 at approximately 1:00 p.m. of Foster Child #1's individual service plan (ISP) dated 09/02/2024, revealed no documentation of the reason for the present placement. Foster Child #1 was placed with the agency approximately nine months ago. A review on 05/01/2025 at approximately 1:00 p.m. of Foster Child #2's individual service plan (ISP) dated 02/22/2024, revealed no documentation of the reason for the present placement. Foster Child #2 was placed with the agency approximately one year ago. During an exit conference on 5/01/2025 at approximately 3:50 p.m. Staff A acknowledged the findings.

Deficiency cited, severity A, foster, re-licensure survey

Based on record review and staff interview, the agency failed to document a semi- annual dental examination (every six months) in one of three foster child records reviewed. Findings include: A review on 5/01/2025 at approximately 2:00 p.m. of Foster Child #2’s record revealed dental examinations dated 02/14/2024 and 08/29/2024. However, there was no other documentation of a completed dental examination in Foster Child #2's record. Foster Child #2 was placed with the agency approximately one year ago. During an exit conference on 05/01/2025 at approximately 3:50 p.m. Staff A acknowledged the findings. Staff A indicated that the dental office made an error in mixing up Foster Child #2 with their sibling and rescheduled Foster Child #2's dental exam for a later date. Staff A further indicated that the agency has rescheduled the dental exam for 05/06/2025.

Deficiency cited, severity D, re-licensure survey

Based on record review and staff interview, the facility failed to document a statement attesting that the employee had never been shown by credible evidence to have abused or neglected a child or an adult in two of five files. Findings include: A review on April 3, 2025, at approximately 10:30 a.m. of Staff C’s file revealed that there was no documentation of a statement attesting that the employee had never abused or neglected a child or an adult. Staff C was hired on September A review on April 3, 2025, at approximately 10:30 a.m. of Staff Es' file revealed that there was no documentation of a statement attesting that the employee had never abused or neglected a child or an adult. Staff E was hired on November During an exit interview on April 3, 2025, at approximately 5:12 p.m. with Staff A and Staff B, Staff A acknowledged the findings. Staff A attempted to locate the document but was unsuccessful.

Deficiency cited, severity D, re-licensure survey

Based on a review of relevant facility documents and staff interviews, the facility failed to document that the staff rehearsed portions of the disaster preparedness plan with a minimum of two rehearsals each calendar year. Findings include: A request on April 3, 2025, at approximately 2:15 p.m. for the disaster plan rehearsal documentation revealed there was no documentation. During an interview with Staff A and Staff B on April 3, 2025, at approximately 5:12 p.m., Staff A acknowledged the findings.