Community Care Licensing

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (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

Document Has Been Signed on 04/18/2024 03:50 PM - It Cannot Be Edited

FACILITY NAME: LINA'S REST HOME I	FACILITY NUMBER: 380503020
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

Type A

Section Cited

CCR

87465(h)(2)

INCIDENTAL MEDICAL CARE 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as medication cabinet in kitchen is unlocked and accessible to clients, which poses an immediate health, safety or personal rights risk to persons in care. Senna, stool softener and rubbing alcohol belonging to staff is observed in living room.
	POC Due Date: 04/18/2024
	Plan of Correction
1 2 3 4	Medication cabinet was locked in LPA's presence. Senna, stool softener, alcohol are removed from living room. Deficiency corrected and cleared. Administrator to ensure that medications are inaccessible to clients at all times.

Type A

Section Cited

CCR

87303(i)(1)(A-C)

MAINTENANCE AND OPERATION Facilities shall have signal systems which shall meet the following criteria: (1) All facilities aving separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as there is no emergency signal system installed, which poses an immediate health, safety or personal rights risk to persons in care. Staff sleep on lower level and residents are on 2nd level.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Emergency call system shall be installed and operable. Clients and staff will be instructed on use. Proof of correction to be sent to CCLD BY DUE DATE.

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024

Document Has Been Signed on 04/18/2024 03:50 PM - It Cannot Be Edited

FACILITY NAME: LINA'S REST HOME I	FACILITY NUMBER: 380503020
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

Type A

Section Cited

CCR

87468.1(a)(2)

PERSONAL RIGHTS (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of room of client #1 , the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. Closet in room of client #1 is used for storage of personal items of staff.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Staff belongings in client room will be removed, so client's room is not used for storage of staff belongings. Proof of correction to be sent to CCLD BY DUE DATE.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024

Document Has Been Signed on 04/18/2024 03:50 PM - It Cannot Be Edited

FACILITY NAME: LINA'S REST HOME I	FACILITY NUMBER: 380503020
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

Type B

Section Cited

CCR

87307(a)

PERSONAL ACCOMMODATIONS AND SERVICES (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and client interviews, the licensee did not comply with the section cited above, as living room is used by staff for sleeping, which poses a potential health, safety or personal rights risk to persons in care. Living room is used by staff for sleeping. Staff medications and personal belongings are stored in living room, so it cannot be used by residents.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Living room shall be accessible to residents at all times. Proof of correction to be sent to CCLD BY DUE DATE.

Type B

Section Cited

HSC

1569.311

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as there are no carbon monoxide detectors maintained, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Carbon monoxide detector(s) shall be installed and operable. Proof of correction to be submitted to CCLD BY DUE DATE.

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024

Document Has Been Signed on 04/18/2024 03:50 PM - It Cannot Be Edited

FACILITY NAME: LINA'S REST HOME I	FACILITY NUMBER: 380503020
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

Type B

Section Cited

CCR

87405(a)

ADMINISTRATOR QUALIFICATIONS AND DUTIES (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff record review, the licensee did not comply with the section cited above, as there is no certified administrator, which poses a potential health, safety or personal rights risk to persons in care. Mr. Bautista does not hold RCFE certification, and Ms. Inguito has expired RCFE certification, expired 2019.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Proof/plan of correction to be submitted to CCLD BY DUE DATE.

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024