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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803007
Report Date: 10/31/2022
Date Signed: 10/31/2022 11:41:37 AM


Document Has Been Signed on 10/31/2022 11:41 AM - 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 #4FACILITY NUMBER:
216803007
ADMINISTRATOR:BAUTISTA, ANAFACILITY TYPE:
740
ADDRESS:344 DEVON DRIVETELEPHONE:
(415) 499-0614
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 5DATE:
10/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ana BautistaTIME COMPLETED:
11:55 AM
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At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required - 1 Year Visit Inspection and met with Administrator, Ana Bautista. Facility currently has 5 residents, and serves residents with dementia. Facility has a plan of operation for dementia care and programming. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival at the facility, LPA had their temperature checked and logged. LPA answered a standard COVID-symptom questionnaire. LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

Facility has a cleaning and disinfecting schedule that occurs at least once per day. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for Residents. Staff and Residents are screened daily for COVID-19 symptoms and it is logged into facility binders.

LPA and Administrator discussed the following: Booster Shots, activities, staffing, incident reports, and training. Facility has a plan in place if a staffing shortage were to occur. Facility submitted their Mitigation/Infection Control Plan to Community Care Licensing (CCL).

Fire extinguisher was last serviced April 2022. Smoke and carbon monoxide detectors were tested and operational. The last facility fire and evacuation drill was conducted August 24, 2022.

Continued on LIC-809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022
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 #4
FACILITY NUMBER: 216803007
VISIT DATE: 10/31/2022
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Continued from LIC-809

LPA requested the following documents to update facility file:
  • Administrative Organization (LIC 309)
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Control of Property (Renewal of Lease) when applicable
  • Liability Insurance

Documents to be submitted to CCL by due date of Wednesday, November 30, 2022.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC809 (FAS) - (06/04)
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