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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803008
Report Date: 10/25/2022
Date Signed: 10/25/2022 11:48:44 AM


Document Has Been Signed on 10/25/2022 11:48 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 # 5FACILITY NUMBER:
216803008
ADMINISTRATOR:BRIAN BAUTISTAFACILITY TYPE:
740
ADDRESS:631 BAMBOO TERRACETELEPHONE:
(415) 479-3556
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 6DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee Ana Belle BautistaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA), Shannan Hansen arrived Unannounced at Terra Linda Christian Homes, Inc #5 for the purpose of conducting a Required 1 year Infection inspection. LPA was greeted at the door by Care Giver, Mai Portacio. Licensee, Ana Belle Bautista arrived 20 minutes later. Facility has 6 residents, 4 with dementia, and 2 on hospice.

LPA toured the facility with licensee, Ana Belle 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 04/07/2022 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Water temperature in resident's bathroom faucets measured between 106.1 degrees F and 120 degrees F which are within acceptable range of Title 22 Regulations of 105 to 120 degrees F. 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 locked hallway closet above washer. 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. Medications are centrally stored in locked cabinet in kitchen but on today’s inspection there were also medications stored in separate kitchen drawer without lock, accessible to residents in care (see LIC 809D). Sharps in kitchen drawer were also unlocked and accessible to residents in care (see LIC 809D).

Infection Control:


Facility has submitted a mitigation program plan and infection control plan. Posters have been placed at facility and entrance has hand sanitizer and other items designated for visitors and staff before coming into facility. Facility has PPE supply stored in backyard storage.

Continue LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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 # 5
FACILITY NUMBER: 216803008
VISIT DATE: 10/25/2022
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In addition, facility has a designated area for visitors which are being allowed for visits. Residents also have available Zoom, Facetime, and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have obtained N-95 fit testing.

LPA Hansen reviewed Licensing Information System (LIS) with Licensee who stated that is corrected and updated at this time. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of current CPR & 1st Aid certification for staff.


Administrator Certificate is for Ana Belle Bautista 6001738740 Exp. 3/12/2023
All staff have received COVID booster vaccinations.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 11/04/2022:

LIC 308 Designated

LIC 309 Administrative Organization

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/25/2022 11:48 AM - 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: TERRA LINDA CHRISTIAN HOMES, INC # 5
FACILITY NUMBER: 216803008

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)


This requirement is not met as evidenced by:87465(h)(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 unlocked drawers with medication located in the kitchen. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2022
Plan of Correction
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Licensee agrees to submit self certification that all medications are locked and inaccessable to residents in care, along with training for staff and to submit to CCL by POC due date of 10/26/2022.
Type A
Section Cited
CCR
87705(h)(1)


This requirement is not met as evidenced by:87705(f)(1)Care of Persons w/Dementia - The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s)
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1out of 1 unlocked kitchen drawer containing knives and other sharps were accessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2022
Plan of Correction
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Licensee to ensure that all sharp objects and toxins are stored in a locked storage inaccessible to residents at all times.Licensee to fix locks on drawer containing sharp objects in kitchen and submit proof of correction. Licensee to also provide training of regulation for caregivers and submit both to CCL by EOB 10/26/2022.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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