415600822-9-24-2021-14-AS-KHOS-C9JNAP-20211209091752

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600822
Report Date: 09/24/2021
Date Signed: 09/24/2021 04:57:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/15/2021 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210915112236

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: 5	DATE:	09/24/2021
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Xerxes Evangelista, Jesse De Guzman,		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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- Resident was improperly evicted

-- There is no facility administrator

INVESTIGATION FINDINGS:

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LPA Jeung met with caregiver and discussed allegations with owner Ron--by phone. LPA asked to speak with administrator or person in charge, to discuss complaint. Staff advised LPA that there was no one in charge for LPA to discuss complaint with.

On 9/15/21, LPA was made aware of client #1, who was denied re-entry to facility after transport to hospital. San Mateo Ombudsman is involved and aware of this. LPA Jeung discussed this with facility staff on 9/15/21 by phone, as well as with licensee's representative.

Based on this information, the preponderance of evidence standard has been met. Therefore, these allegations are determined to be substantiated.

Deficiencies of the CA Code of Regulations, Title 22 are cited on a following page.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20210915112236

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 CCR 87224(f)	1 2 3 4 5 6 7	EVICTION PROCEDURES (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met, as eviction notice for this client was submitted to CCLD on 9/15/21, but dated 7/1/21. Licensee failed to submit timely eviction	1 2 3 4 5 6 7	Licensee to submit written acknowledgement of proper and timely submission of eviction notices to CCLD BY DUE DATE
	8 9 10 11 12 13 14	notice to CCLD within 5 days of notice, which posed a potential health, safety or personal rights risk to client.	8 9 10 11 12 13 14
Type B 10/01/2021 Section Cited CCR 87468.2	1 2 3 4 5 6 7	ADDITIONAL PERSONAL RIGHTS Residents in privately operated RCFEs shall have the right to be protected from involuntary transfers,discharges,evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations & shall comply with all eviction & relocation protections for residents.	1 2 3 4 5 6 7	Licensee to submit written acknowledgement to CCLD BY DUE DATE that residents will be accorded the rights to be served with proper eviction procedures, as per Title 22 regulations,
	8 9 10 11 12 13 14	For purposes of this paragraph, "involuntary" means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident. This requirement was not met, as facility staff told hospital staff that client #1 was not allowed to return to facility on 9/14/21, when she was medically cleared. Licensee failed to abide by Title 22 regulations & eviction notice dated 7/1/21, which posed a potential health, safety & personal rights risk to client.	8 9 10 11 12 13 14

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 Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 14-AS-20210915112236

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 CCR 87405(a)	1 2 3 4 5 6 7	ADMINISTRATOR QUALIFICATIONS/ DUTIES All facilities shall have a qualified and currently certified administrator... The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility...	1 2 3 4 5 6 7	Plan of correction to be submitted to CCLD BY DUE DATE
	8 9 10 11 12 13 14	This requirement is not met, as evidenced by facility staff, who stated to LPA on 9/15/21 & today, 9/24/21, that there was no administrator, and that he reports to the owner. Licensee failed to ensure that there is a certified RCFE administrator to manage facility operations, which poses a potential health, safety and personal rights risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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