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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380503020
Report Date: 11/04/2023
Date Signed: 11/04/2023 03:01:26 PM


Document Has Been Signed on 11/04/2023 03:01 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:LINA'S REST HOME IFACILITY NUMBER:
380503020
ADMINISTRATOR:FLOR BAUTISTAFACILITY TYPE:
740
ADDRESS:393 SILVER AVENUETELEPHONE:
(415) 586-8171
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:6CENSUS: 5DATE:
11/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Flor Bautista, Julie ArgaoTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct an annual required inspection. LPA met with Licensee/Administrator Flor Bautista, and explained the purpose of the visit. Administrator Flor was dropping off groceries for the facility and left after speaking to LPA Valerio. LPA Valerio and Administrator Flor discussed licensing fees and informed LPA that the licensee address has been incorrect for a few years. Administrator requested that the mailing address be changed to the facility address. Administrator Flor designated facility staff, Julie Argao, to carry out the rest of the visit.

LPA Valerio and Facility staff, Julie, toured the facility to ensure compliance with Title 22 regulations. LPA observed 3 resident bedrooms. LPA observed 5 residents in care. Resident bedrooms were equipped with necessary furniture and furnishings with no emergency exits being obstructed. The facility has one shared bathroom that was observed to have handrails, skid mats, soap, paper towels, toilet paper, hand sanitizer, and a trash can with a lid. Hot water was measured at 115.7*F, which is within the regulatory range of 105-120*F. Common areas were observed to have necessary furniture. The facility temperature was at a comfortable temperature. The facility was observed to have a minimum supply to meet the requirements of 7 days of non-perishables and 2 days of perishable food items. An emergency supply of food and water were observed. A first aid kit was available and fully stocked. Last Emergency Disaster Drill was conducted on 09/2023. Fire extinguishers were observed to be fully charged with a last inspection on 10/30/2023. Carbon monoxide detectors were observed in each bedroom and common area.

LPA reviewed facility files, resident files, and staff files. LPA spoke to multiple staff and resident during the visit. LPA requested the following documentation to be sent to the San Bruno Regional Office: LIC 9282 - Infection Control Plan, LIC 500, LIC 308, Control of Property, LIC 610D, Liability Insurance

Per California Code of Regulations (CCR), Title 22 - Technical advisory was provided and deficiencies cited on LIC 809 - D. Appeal rights provided. An exit interview was held, and a copy of the report provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2023
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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Document Has Been Signed on 11/04/2023 03:01 PM - 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: LINA'S REST HOME I
FACILITY NUMBER: 380503020

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 2 out of 2 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Licensee stated they will update all resident files by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2023
LIC809 (FAS) - (06/04)
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