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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380503020
Report Date: 04/18/2024
Date Signed: 04/18/2024 01:17:23 PM


Document Has Been Signed on 04/18/2024 01:17 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
SF COASTAL AC/SC, 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: 4DATE:
04/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Julie Argao and Carmen ArgaoTIME COMPLETED:
01:15 PM
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In response to Incident Report and Death Report received on 4/8/24 for client who passed on 4/5/24, LPA Jeung reviewed client's file and obtained details from staff, who was present when client #1 passed away.

LPA requested that Death Certificate be obtained and a copy sent to CCLD within SEVEN DAYS.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
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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