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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600822
Report Date: 12/02/2022
Date Signed: 12/02/2022 10:42:50 AM


Document Has Been Signed on 12/02/2022 10:42 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:
12/02/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Caregiver, Ryan Galang TIME COMPLETED:
10:53 AM
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On December 2, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced plan of correction (POC) visit to verify and to confirm that the facility is in compliance with the citations that were issued on 11/14/22. LPA Charitra met with Caregiver, Ryan Galang and explained the purpose of the visit.

On 11/14/22, the facility was cited for California Code of Regulation (CCR), 87307(a)(2)(B) Personal Accommodations, 87616(a) Exceptions for Health Conditions, 87464(f)(1) Basic Services, 87468.1(a)(2) Personal Rights of Residents in All Facilities, 87506(b)(17) Resident Records, 80068.2(a) Needs and Services Plan, 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities.

The plan of correction for citation 87468.1(a)(2) Personal Rights of Residents in All Facilities was due to CCLD by 11/15/22 and the plan of correction for citations, 87307(a)(2)(B) Personal Accommodations and 87616(a) Exceptions for Health Conditions, was due to CCLD by 11/21/22, however the facility administrator failed to provide CCLD a plan of correction by the due date. In addition, facility administrator did not ask CCL for an extension.

During the visit, administrator was not present, and caregiver was unable to provide LPA with a POC for the cited deficiencies. Due to the citation 87468.1(a)(2) Personal Rights of Residents in All Facilities, not being corrected by 11/15/22, a civil penalty is being assessed in the amount of $100 a day from 11/15/22 through 12/2/22 and will continue to accrue until corrected.

Due to the citations, 87307(a)(2)(B) Personal Accommodations and 87616(a) Exceptions for Health Conditions, not being corrected by 11/21/22, a civil penalty is being assessed in the amount of $100 a day from 11/21/22 through 12/2/22 and will continue to accrue until corrected.

Report is reviewed with Caregiver, and a copy is provided with appeals rights. A copy of the civil penalty is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
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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