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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600822
Report Date: 12/14/2022
Date Signed: 12/14/2022 12:06:18 PM


Document Has Been Signed on 12/14/2022 12:06 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: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:
12/14/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Caregiver, Ryan GalangTIME COMPLETED:
12:25 PM
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On December 14, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced plan of correction (POC) visit to follow up on a POC visit made on 12/2/2022. LPA Charitra met with Caregiver, Ryan Galang and explained the purpose of the visit.

On 12/2/2022, LPA visited the facility to confirm that the facility is in compliance with the citations that were issued on 11/14/22. The facility administrator was unable to provide LPA with plan of corrections for the deficiencies cited on 11/14/2022 by due date. LPA issued three civil penalties during the visit from the day after the plan of correction was due till 12/2/22 and notified the caregiver and administrator that the civil penalty will continue to accrue until corrected.

On 12/13/2022, LPA received the plan of corrections for the deficiencies cited. Deficiency is now verified as corrected and cleared.

Civil penalty will be assessed from 12/3/2022 through 12/13/2022 for violations: 87468.1(a)(2) Personal Rights of Residents in All Facilities, 87307(a)(2)(B) Personal Accommodations and 87616(a) Exceptions for Health Conditions. Civil penalties are stopped on 12/13/2022.

Total civil penalty assessed today for 87468.1(a)(2) Personal Rights of Residents in All Facilities = $1,100.00
Total civil penalty assessed today for 87307(a)(2)(B) Personal Accommodations= $1,100.00
Total civil penalty assessed today for 87616(a) Exceptions for Health Conditions= $1,100.00

Report is reviewed with Ryan Galang and a copy is provided with appeals rights. Civil penalties are also provided to Caregiver.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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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