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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600822
Report Date: 11/14/2022
Date Signed: 11/14/2022 11:46:04 AM


Document Has Been Signed on 11/14/2022 11:46 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: 5DATE:
11/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Caregiver, Ryan GalangTIME COMPLETED:
12:00 PM
NARRATIVE
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On November 14, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in reference to complaint #14-AS-20220829121359. LPA met with Caregiver, Ryan Galang and explained the purpose of the visit. LPA was screened at entry point.

LPA Charitra visited the facility on 8/31/22 and observed two staff members without a face mask on while assisting residents in care.

Furthermore, during the complaint investigation, it was acknowledged by the Administrator that he failed to assess Resident #1 (R1) prior to his/her admission to the facility. Based on R1’s file reviewed, the facility failed to reassess R1 after it was noted R1 had a change of condition. In addition, LPA did not observe any care plan documented to indicate how the facility is providing care for R1 to meet his/her needs and services.

In addition, based on R1’s hospital discharge documents, it was noted by R1’s physician, that R1 needed to be weighed every morning due to his/her medical condition, however according to the staff interviewed, the facility did not have adequate equipment to weigh R1. Nevertheless, the facility failed to follow physician’s orders and weigh R1 every morning.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Caregiver, Ryan Galang and a copy is provided with appeals rights,
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022
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


Document Has Been Signed on 11/14/2022 11:46 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: 11/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2022
Section Cited

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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

Violation of this regulation is evidenced by:
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Based on observations during LPA's visit, LPA observed two staff members on 8/31/22, without a face mask on while assisting residents which poses an potential health and safety risk to residents in care
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Type B
11/21/2022
Section Cited

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87506 Resident Records: (b) Each resident’s record shall contain at least the following information:(17) Documents and information required by the following ... Pre-Admission Appraisal, Functional Capabilities, Mental Condition, Social Factors, Reappraisals; and Documentation and Support.

Violation of this regulation is evidenced by:
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Based on R1's file reviewed, the facility failed to ensure R1's file had all required forms and documents listed above in R1's file.
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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: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 11/14/2022 11:46 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: 11/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2022
Section Cited

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80068.2 Needs and Services Plan: (a) The licensee shall complete a Needs and Services Plan for each client as required...

Violation of this regulation is evidenced by:
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Based on the file reviewed, the facility failed to complete and maintain a needs and service plan for R1 in his/her files which poses an potential health and safety risk to residents in care
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Type B
11/21/2022
Section Cited

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

Violation of this regulation is evidenced by:
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Based on interviews conducted, the facility failed to provide care to meet the needs as evidenced by not weighing R1 every morning as indicated by R1's physician.
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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: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3