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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600822
Report Date: 06/10/2021
Date Signed: 06/10/2021 04:34:45 PM

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:LINCOLN RESIDENCE 653 CARE HOME BY RNSFACILITY NUMBER:
415600822
ADMINISTRATOR:BAUTISTA, ALEXANDERFACILITY TYPE:
740
ADDRESS:653 COMMERCIAL AVENUETELEPHONE:
(650) 952-1941
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 5DATE:
06/10/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:48 PM
MET WITH:Ryan GalangTIME COMPLETED:
04:35 PM
NARRATIVE
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On June 10, 2021 Licensing Program Analyst (LPA) Chris Hopkins, conducted a case management on-site visit. LPA Hopkins met with caregiver Ryan Galang and explained the purpose of the visit.

This case management relates to Complaint 14-AS-20210513140959 dated 5/13/21. During the course of investigating the complaint, LPA Hopkins found that former Administrator was asking and receiving direct payment for transportation services. LPA received copies of checks made out to the former Administrator totaling $425. The facility failed to make appropriate arrangements for transporting residents.

A deficiency of the California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.1 is observed and cited on the following LIC809-D page.

This report was discussed and reviewed with caregiver Ryan Galang.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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: LINCOLN RESIDENCE 653 CARE HOME BY RNS
FACILITY NUMBER: 415600822
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2021
Section Cited

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87468.1(a)(3) Personal Rights of Residents in All Facilities- (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) to be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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This requirement is not met as evidenced by: Based on interviews and documentation, Licensee did not ensure that residents personal rights were being met, due to former Administrator directly requesting and accepting money from the responsible party, which poses a potential health, safety and personal rights risk to residents in care.
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2021
LIC809 (FAS) - (06/04)
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