380503020-9-28-2021-14-AS-MGAA-C7ALFW-20210928084349

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380503020
Report Date: 09/21/2021
Date Signed: 09/28/2021 08:44:14 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	LINA'S REST HOME I		FACILITY NUMBER:	380503020
ADMINISTRATOR:	BAUTISTA, AQUILINA E.		FACILITY TYPE:	740
ADDRESS:	393 SILVER AVENUE		TELEPHONE:	(415) 586-8171
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94112
CAPACITY:	6	CENSUS: 6	DATE:	09/21/2021
TYPE OF VISIT:	Case Management - COVID-19	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Flor Bautista and Julie Argao		TIME COMPLETED:	03:30 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	On September 21, 2021, Licensing Program Analyst (LPA) Michael Garcia conducted a Case Management tele-visit to provide Technical Assistance (TA) to the facility regarding COVID-19. The TA visit was conducted with facility administrator Flor Bautista, and facility caregiver Julie Argao with the assistance from Licensing Program Clinical Consultant Cristina Wong, and Licensing Program Manager Brenda Chan. The facility's COVID-19 mitigation protocol was discussed. First and second floors of the facility were toured. The facility has 4 active COVID-19 residents, 2 of which are isolating in a hotel being monitored by San Francisco Public Health according to Flor. The TA visit resulted with the following recommendations: - Post mask required at the front door. - Document proof of vaccination status or proof of negative test results from visitors. Negative test result shall be within 72 hours prior to visit. - Place paper towel inside the staff's restroom. - Place a trash can by the kitchen (foot operated preferred). - Ensure all trash cans have lid. Foot operated trash cans preferred. - Ensure each cleaning solution contained in a separate bottle is labeled, and used within 24 hours. - Post cough etiquette poster by the living room and other common areas and hallways. - Post droplet precaution sign outside the door of the COVID-19 positive resident's room. - Post sign of proper donning of PPE outside the door and proper doffing of PPE inside the door of the COVID-19 resident's room. - Place PPE supplies at the 2nd floor. CONTINUE ON NEXT PAGE...

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael Garcia	TELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: LINA'S REST HOME I	FACILITY NUMBER: 380503020
	VISIT DATE: 09/21/2021

NARRATIVE

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- Request training from DPH regarding proper donning and doffing of PPE, and how to conduct proper sealed check for N95.
- Use disposable plates and utensils for COVID-19 positive residents.
- Refrain from using cloth towels.
- Provide hand sanitizers for each resident.
- Ensure facility is signed up in receiving Provider Information Notices (PINs) from CCL.
- Refer to PIN 21-40-ASC for visitation guidelines and PIN 21-43-ASC for COVID-19 mitigation plan.

Administrator shall ensure to email a signed and dated action plan regarding the above recommendations to LPA within 24 hours.

Report reviewed and discussed with administrator at the end of the visit.

An electronic copy of the report was emailed to administrator for signature.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael Garcia	TELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC809 (FAS) - (06/04)

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