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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600822
Report Date: 01/19/2023
Date Signed: 01/19/2023 10:41:57 AM


Document Has Been Signed on 01/19/2023 10:41 AM - 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: 6DATE:
01/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Caregiver, Ryan GalangTIME COMPLETED:
10:50 AM
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On January 19, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit. LPA met with Caregiver, Ryan Galang and explained the purpose of the visit.

During an annual inspection conducted on November 14, 2022, LPA Charitra cited the facility for Section 87307(a)(2)(B) Personal Accommodation and Services,as a result of the facility utilizing a bathroom as a sleeping area for staff. The facility’s plan of correction was to submit a new facility floor plan to CCLD to request for a new fire clearance.

On December 19, 2022, the City of South San Francisco Fire Department conducted a fire inspection at the facility. According to the Fire Department, the Store Room (indicated on facility floor plan) and Bathroom A (indicated on facility floor plan) currently have sleeping items, however due to the lack of emergency exiting, those rooms are not allowed to have sleeping items.

During the visit, LPA toured the facility and observed the Store Room and Bathroom A. Bathroom A no longer has a bunk bed, and according to the caregiver, no staff are sleeping in Bathroom A. The Store Room is used to store extra supplies for residents and toiletries.

The facility is going to utilize Bathroom A as a bathroom and a storage room. In addition, the facility hired a contractor to inspect and install appropriate sprinkler system to meet county requirements. A new facility floor plan will be provided to LPA for another fire clearance once sprinkler systems are checked and inspection is conducted by a licensed contractor.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with Caregiver; a copy of the report is provided with appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/19/2023 10:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 RNS
FACILITY NUMBER: 415600822

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited

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87203 FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

Violation of this regulation is not met as evidenced by:
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During the visit LPA Charitra observed that the bathroom did not have bunk bed present. In addition, there were no staff belongings present.
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Based on observations and information collected, the licensee did not compy with the section cited above, as the bathroom was being utilized by staff for sleeping, however was not cleared by fire department, which poses an immediate health, safety, or personal rights risk to persons 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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
LIC809 (FAS) - (06/04)
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