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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415600822
Report Date:
06/19/2024
Date Signed:
06/19/2024 06:07:59 PM
Document Has Been Signed on
06/19/2024 06:07 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:
LINCOLN RESIDENCE 653 CARE HOME BY RNS
FACILITY NUMBER:
415600822
ADMINISTRATOR:
BAUTISTA, ALEXANDER
FACILITY TYPE:
740
ADDRESS:
653 COMMERCIAL AVENUE
TELEPHONE:
(650) 952-1941
CITY:
SOUTH SAN FRANCISCO
STATE:
CA
ZIP CODE:
94080
CAPACITY:
6
CENSUS:
4
DATE:
06/19/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
03:33 PM
MET WITH:
Raine Galang
TIME COMPLETED:
06:25 PM
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On 6/19/24 LPA Grace Donato conducted an unannounced annual visit to the facility. LPA met with the Care Staff Raine Galang and explained the purpose of the visit.
LPA toured the facility inside and outside. While touring the facility it was observed that the temperature was af 69 deg F. Hot water was also tested and temperature was 108 deg F. Each resident rooms were checked. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. All residents are comfortable and taken care of. Carbon monoxide monitor is working properly. All fire extinguishers have been checked. Bathrooms were observed to be in good repair equipped with non-skid mats and grab bars. There is also adequate amount of food. 2 days for perishables and & 7 days non-perishable. Sharps and toxic materials are locked. Emergency drills are done quarterly.
Medication review was done and all medications are accounted for and centrally stored medication records are updated.
Four staff records and four resident records was reviewed. All staff has criminal record clearance and are associated with the facility. Resident records are checked and all are complete and updated.
Licensee to submit Liability Insurance and LIC500.
No deficiency cited today. Report is reviewed and copy is provided.
SUPERVISOR'S NAME:
Andrea Medlin
TELEPHONE:
(650) 266-8811
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
06/19/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/19/2024
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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