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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803007
Report Date: 11/19/2023
Date Signed: 11/19/2023 01:19:20 PM


Document Has Been Signed on 11/19/2023 01:19 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 #4FACILITY NUMBER:
216803007
ADMINISTRATOR:BAUTISTA, ANAFACILITY TYPE:
740
ADDRESS:344 DEVON DRIVETELEPHONE:
(415) 499-0614
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 5DATE:
11/19/2023
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ana Bautista, AdministratorTIME COMPLETED:
01:20 PM
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At approximately 10:00AM on 11/19/2023, Licensing Program Analyst (LPA) Jill Nakagawa 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.

Upon arrival at the facility, LPA had temperature checked and answered a standard COVID-symptom questionnaire. LPA conducted a walk-through of the facility and observed the following: All staff present were observed to be wearing a mask. The facility was found to be clean andt a comfortable temperature of 71 F with all exits free from obstruction. Facility submitted their Mitigation and Infection Control Plans to Community Care Licensing (CCL).

Fire extinguisher was last serviced on 08/30/23. Smoke and carbon monoxide detectors were tested and operational. The fire alarm system was last inspected and serviced 08/2023. The last facility fire and evacuation drill was conducted on 10/01/2023. The water temperature measured between 105-118 F which is within regulation. There were ample perishable and non-perishable foods as required by regulation and foods were stored as required: sealed and dated. Bathrooms were furnished with soap, paper towels and covered trash containers. There was an ample supply of clean linens. Beds were made with required linens, including mattress pad covers, and had plenty of blankets for the colder weather ahead.

Continued on 809-C..

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2023
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 #4
FACILITY NUMBER: 216803007
VISIT DATE: 11/19/2023
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Continued from 809


LPA requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Control of Property (Renewal of Lease)
  • Liability Insurance

Documents to be submitted to CCL by due date of 12/5/2023.

No deficiencies found at the time of inspection. No citations issued.

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: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2023
LIC809 (FAS) - (06/04)
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