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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803006
Report Date: 11/07/2024
Date Signed: 11/07/2024 01:18:38 PM

Document Has Been Signed on 11/07/2024 01:18 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:TERRA LINDA CHRISTIAN HOMES, INC # 2FACILITY NUMBER:
216803006
ADMINISTRATOR/
DIRECTOR:
ANABELLE BAUTISTAFACILITY TYPE:
740
ADDRESS:598 KERNBERRYTELEPHONE:
(415) 479-0266
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Staff Members, Loida Paningbaatan, Cristostomo Nario, and Administrator/Licensee, Ana Belle BautistaTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
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At approximately 9:35AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Staff Members, Loida Paningbaatan and Cristostomo Nario. Designated Representative, Bella Nachor, arrived during visit at approximately 10:10AM. Licensee, Ana Belle Bautista, arrived during visit at approximately 10:20AM. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents. Facility has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were 6 residents in care and 2 staff members on-site.

At approximately 9:45AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 9:50AM, LPA conducted a walk-though of the facility with Staff Member. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 5 Resident bedrooms, a staff room, 3 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Residents. Mattress pads were in place or available for Resident use. Hot water temperatures for sinks in facility were found to be at the following temperatures, 120.5F, 116.6F, 113.3F, and 123.4F. LPA observed that facility has signage stating that hot water temperatures may exceed 125F and to use caution. Fire extinguishers were last inspected June 2024. Smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted June 2024 (technical violation issued, LIC9102, H&S Code 1569.695(c)). During walkthrough, LPA observed two Lysol disinfectant sprays in a resident's bathroom. Lysol was removed from resident's bathroom and was locked inaccessible (deficiency cited, LIC809D, regulation 87705(f)(2)).

At approximately 11:00AM, LPA reviewed staff files, resident files and resident medication. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was observed to be centrally stored and secure.

Continued on LIC809C

Victoria BertozziTELEPHONE: (707) 588-5059
Caitlynn FeliasTELEPHONE: 707-588-5039
DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TERRA LINDA CHRISTIAN HOMES, INC # 2
FACILITY NUMBER: 216803006
VISIT DATE: 11/07/2024
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Continued from LIC809

Administrator's Certificate for Ana Belle Bautistia (7000300740) was current with an expiration date of 3/12/2025.

LPA requested the following documents to update facility file:

  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610E)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate


Documents to be submitted to Community Care Licensing (CCL) by due date of 12/07/2024.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Designated Representative. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/07/2024 01:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: TERRA LINDA CHRISTIAN HOMES, INC # 2

FACILITY NUMBER: 216803006

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/07/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87705 Care of Persons with Dementia:(f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication... alcohol... and toxic substances...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above. Two cans of Lysol disinfectant spray were observed in R1’s bathroom. This poses an immediate health and safety risk to residents in care.
POC Due Date: 11/08/2024
Plan of Correction
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Licensee to submit self certification that an In-service training will be conducted for all staff by POC due date of 11/08/2024. Training to review items that are inaccessible to residents in care. Licensee to conduct Inservice Training that includes the following: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 11/17/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria BertozziTELEPHONE: (707) 588-5059
Caitlynn FeliasTELEPHONE: 707-588-5039

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024

LIC809 (FAS) - (06/04)
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