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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600822
Report Date: 09/24/2021
Date Signed: 09/24/2021 05:04:01 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:
09/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Xerxes Evangelista, Jesse De Guzman, Alex BautistaTIME COMPLETED:
05:30 PM
NARRATIVE
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During complaint investigation, LPA Jeung observed deficiencies of the CA Code of Regulations, Title 22.

Upon arrival to facility, two caregivers are present. After LPA introduced herself, she was invited inside. No questions were asked about Covid symptoms, exposure, or temperature, nor was LPA asked to sign visitor log. Both caregivers were not wearing any face coverings. There are no Covid reminder signs posted to wear masks or practice social distancing, but handwashing reminder signs are posted at sinks in bathroom and kitchen. LPA toured facility.

The following updated licensing forms are requested to be sent to CCLD by 10/1/21:

- Personnel Report (LIC 500)
- Designation of Administrative Responsibility (LIC308)

Citations appear on following page.


***Note: Mr. Bautista is authorized to receive this report per owner, Ron Ordona, who is advised that Mr. Bautista no longer maintains criminal record clearance nor association with this facility
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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 3
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: 09/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2021
Section Cited

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PERSONAL ACCOMMODATIONS SERVICES
All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met, as several boxes and clothes hanging on rolling clothes rack are observed blocking door marked with EXIT sign in front bedroom, which is occupied by 2 clients.
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Licensee failed to ensure that designated exit door is free of obstruction, which poses an immediate health and safety risk to clients in care.
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Type A
09/27/2021
Section Cited

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CRIMINAL RECORD CLEARANCE
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility obtain a CA clearance or a criminal record exemption as required by the Department .
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This requirement was not met, as staff JD does not maintain criminal record clearance and association to this facility. Licensee failed to ensure that all persons with client contact have criminal record clearance and association to facility, which poses an immediate health, safety or personal rights risk to clients. Immediate civil penalty of $100 is issued.
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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: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 09/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2021
Section Cited

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MAINTENANCE AND OPERATION
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met, as there are no COVID reminder signs posted to wear masks
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and practice social distancing. Licensee failed to ensure that signs are posted for masks to be worn by staff at all times, and social distancing should be practiced. Failure to post these Covid reminder signs poses a potential health, safety, or personal rights risk to clients in care.
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Type B
10/01/2021
Section Cited

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PERSONNEL REQUIREMENTS GENERAL
All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill, as appropriate, for the job assigned and as evidenced by safe and effective job performance. This requirement is not met,
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as staff did not check LPA for COVID symptoms, exposure, or temperature, nor are staff and clients checked daily for COVID symptoms and temperature. Licensee failed to ensure that COVID infection control measures are taken and practiced, which poses a potential health and safety risk to clients 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: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2021
LIC809 (FAS) - (06/04)
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