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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601364
Report Date: 02/24/2021
Date Signed: 02/24/2021 05:28:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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: 36DATE:
02/24/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Divina Fernandez, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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On 2/24/2021 at 1:30PM, Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit Case Management as a result of a change in ownership. Tele-visit was completed via FaceTime due to shelter in place directed by the Governor. LPA spoke with Administrator, Divina Fernandez.

During the Tele-visit, LPA toured facility with Administrator including but not limited to resident's bedrooms, bathrooms, dining room, common area, kitchen, and outdoor area.

The following are the deficiencies were found during Pre-Licensing Inspection:

At 2:26PM, LPA observed common areas of facility does not have carbon monoxide detectors.

At 2:35PM, LPA observed shared bathrooms did not have paper towels available.


The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health and Safety Code. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights will be emailed.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LINCOLN VILLA
FACILITY NUMBER: 015601364
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/12/2021
Section Cited

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Carbon monoxide detectors required; inspection. Every residential care facility for the elderly shall have one or more carbon monoxide detectors... This requirement is not met as evidence
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by: Based on observation, licensee did not comply with the section cited above to have carbon monoxide detectors in common areas which poses a potential health and safety risk to the residents in care.
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Type B
03/12/2021
Section Cited

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Personal Accommodations and Services. ...The use of common wash cloths and towels shall be prohibited.... This requirement is not met as evidence by:
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Based on observation, licensee did not comply with the section cited above to have common towels for hand drying which poses a potential health and safety risk to the residents 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2021
LIC809 (FAS) - (06/04)
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