216803006-11-7-2023-21-AS-SHAN-CXCTQA-20231107135536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803006
Report Date: 11/07/2023
Date Signed: 11/07/2023 01:55:51 PM

Document Has Been Signed on 11/07/2023 01:55 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	TERRA LINDA CHRISTIAN HOMES, INC # 2		FACILITY NUMBER:	216803006
ADMINISTRATOR:	ANABELLE BAUTISTA		FACILITY TYPE:	740
ADDRESS:	598 KERNBERRY		TELEPHONE:	(415) 479-0266
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	6	CENSUS: 6	DATE:	11/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Anabelle Bautista, Licensee/Administrator		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required - 1 yr. visit of the facility. LPA was welcomed by staff Loida Paningbatan. Anabelle Bautista - Licensee was contacted by staff and arrived during the visit. There is a total of 6 residents, 3 with a diagnostic of dementia. There is 3 residents currently on Hospice. LPA toured the facility on 11/07/2023 at 9:10 AM with administrator Anabelle Bautista; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 5/15/2023 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 105.1 degrees F and 128.3 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 1 of 2 resident’s bathrooms while touring facility on 11/07/2023 although facility has required signage indicating caution, water temp may exceed 125. However, facility licensee is working with a professional to fix the hot water temperature. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in the closet in the hallway over laundry. The bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations # 87307 on 11/07/2023. A review of 6 resident & 3 staff records as well as two resident’s medications was conducted during this visit. LPA reviewed resident’s files at 10:30 AM on 11/07/2023 and learned that 6 of 6 residents have an updated re-appraisals/needs & care plans and updated physician’s assessments (LIC 602A) on file. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TERRA LINDA CHRISTIAN HOMES, INC # 2	FACILITY NUMBER: 216803006
	VISIT DATE: 11/07/2023

NARRATIVE

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Medications were centrally stored in locked cabinet in the facility kitchen area. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 11/07/2023 at 1:30 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be completed and accurate.

LPA reviewed a sample of staff records and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff files have proof of annual training requirements for 2022 and 2023 on file. LPA was presented with proof of CPR & 1^st Aid certification for staff that files were reviewed. Ana Belle Bautista Administrator Certificate # 6001738740 expires on 3/12/2025.

Facility to ensure that approved Admissions Agreements are always posted and/or accessible to public view in the facility as per Title 22 Regulations # 87507 (e)(2) Admissions Agreement “The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility.”

LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills are conducted quarterly with the latest on 9/15/2023.

There were no deficiencies cited at this time.

Continue on LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TERRA LINDA CHRISTIAN HOMES, INC # 2	FACILITY NUMBER: 216803006
	VISIT DATE: 11/07/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	LPA Hansen is requesting facility to submit the following documents to CCL by 11/30/2023: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Current Administrators Certificate Copy of New 3 yr Lease of Property Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC809 (FAS) - (06/04)

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