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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380503020
Report Date: 07/15/2024
Date Signed: 07/15/2024 05:35:15 PM

Document Has Been Signed on 07/15/2024 05:35 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/
DIRECTOR:		FLOR BAUTISTAFACILITY TYPE:
740
ADDRESS:393 SILVER AVENUETELEPHONE:
(415) 586-8171
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 6CENSUS: 0DATE:
07/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:15 PM
MET WITH:Julie ArgaoTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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In response to letter dated 6/19/24--received in San Bruno regional office on 6/28/24--of facility closure, LPA Jeung verified that there are no residents in care. Three bedrooms on 2nd floor of facility are vacant.

RCFE license is surrendered to LPA. Forfeiture letter is forthcoming.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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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