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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803008
Report Date: 09/14/2021
Date Signed: 09/14/2021 02:19:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:TERRA LINDA CHRISTIAN HOMES, INC # 5FACILITY NUMBER:
216803008
ADMINISTRATOR:BRIAN BAUTISTAFACILITY TYPE:
740
ADDRESS:631 BAMBOO TERRACETELEPHONE:
(415) 479-3556
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 6DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator, David SekirandaTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Terra Linda Christian Homes, Inc #5. Unannounced for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Administrator, David Sekiranda.

LPA toured the facility with Administrator, David Sekiranda; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers was found to be last charged on 04/2021 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 116 degrees F and 117 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms while touring facility. 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 locked and inaccessible to residents in care. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with community towels and hand soap dispensers instead individual hand towels. 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.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE in the office located and at other sister sites. Facility is in the process of being N95 Fit tested on September 22, 2021. No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, David Sekiranda.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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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