216803008-11-19-2023-21-AS-JNAA-CXQW3D-20231119155547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803008
Report Date: 11/19/2023
Date Signed: 11/19/2023 03:56:09 PM

Document Has Been Signed on 11/19/2023 03:56 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 # 5		FACILITY NUMBER:	216803008
ADMINISTRATOR:	BRIAN BAUTISTA		FACILITY TYPE:	740
ADDRESS:	631 BAMBOO TERRACE		TELEPHONE:	(415) 479-3556
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	6	CENSUS: 6	DATE:	11/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Ana Bautista, Licensee		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA)Jill Nakagawa 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 House Manager Jessica Tadaya. LPA toured the facility with House Manager. 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 11/10/2023. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured 109 degrees which is within Title 22 acceptable regulation 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 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 paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22. Medications are stored and locked in cabinet in kitchen. Continued on 809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 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 # 5	FACILITY NUMBER: 216803008
	VISIT DATE: 11/19/2023

NARRATIVE

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Continued from 809.....

The backyard was free of debris and provided lots of space for residents to move about and socialize. There were several fruit trees which the residents
enjoy watching them change from season to season.

At the time of visit, residents were socializing together in the living room, watching a Christmas movie and enjoying conversation and popcorn.

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 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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