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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601364
Report Date: 08/28/2020
Date Signed: 08/28/2020 09:11:41 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/14/2020 and conducted by Evaluator Yvonne Flores-Larios
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200514083809
FACILITY NAME:LINCOLN VILLAFACILITY NUMBER:
015601364
ADMINISTRATOR:BROWN, DEBORAFACILITY TYPE:
740
ADDRESS:41040 LINCOLN AVENUETELEPHONE:
(510) 656-4373
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:76CENSUS: 46DATE:
08/28/2020
ANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Divine Fernandez, Resident Care DirectorTIME COMPLETED:
09:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident has unexplained burn marks and bruising
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/28/2020 Licensing Program Analyst (LPA) Y. Flores-Larios conducted an announced tele-visit with Divine Fernandez, to provide investigative findings on the allegation above. Due to shelter in place orders issued by the Govenor findings were delivered via tele-visit.

During the course of the inverstigation the Department conducted interviews with residents, facility staff, and medical parties involved in R1 care. In additon obtained hosital records regarding allegation. Based off interviews conducted and documentation received R1 has history of skin breakdown and on medication that could cause bruising. Interviews that were conducted with staff were inconclusive if R1 had any blisters or bruising that were reported. Hospital notes from dates 4/22/2020-5/4/2020 did not note any blisters or bruising during the time R1 was hospitalized. While at the facility in the days leading up to subsequent hospitalization on 5/11/2020 facility does not have any notation in R1's file of any bruising or blisters. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted and a copy of this report sent via email.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2020
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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