015601364-4-29-2022-15-AS-KHOS-CEGK9D-20220516074211

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601364
Report Date: 04/29/2022
Date Signed: 04/29/2022 11:15:32 AM

Unsubstantiated

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
03/11/2020 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20200311105744

FACILITY NAME:	LINCOLN VILLA		FACILITY NUMBER:	015601364
ADMINISTRATOR:	BROWN, DEBORA		FACILITY TYPE:	740
ADDRESS:	41040 LINCOLN AVENUE		TELEPHONE:	(510) 656-4373
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	0	CENSUS: 49	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Divina Fernandez, Administrator		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff handled resident in a rough manner.

Resident is not accorded dignity in her personal relationships with staff.

Facility is not providing food of the quantity necessary to meet the needs of resident.

Staff put resident to bed at 5 p.m.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 4/29/2022 at 09:30AM, Licensing Program Analysts (LPAs), L. Hall and Liridon Fici arrived unannounced to conduct a complaint investigation and to deliver complaint findings for the allegations above. LPA met with Divina Fernandez, Administrator and explained the reason for the visit.

During the investigation LPA Y. Flores-Lairos interviewed staff. Staff stated that residents are not handled in a rough manner. LPA L. Hall interviewed five (5) residents that stated the staff treats them well. Residents stated they are not handled in a rough manor.

On the allegation resident is not accorded dignity in her personal relationships with staff. During interviews with staff and residents it was stated that they are called by their name. Residents stated that if staff forgets their name the staff will say Sir or Ma'am.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 15-AS-20200311105744

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 04/29/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099.

On the allegation facility is not providing food of the quantity necessary to meet the needs of residents. LPA Y. Flores-Lairos collected 2 weeks of the daily menu. The menu showed a variety of food and drinks. Interview with S3 indicated residents are served 4 oz meat, a scoop of starches and vegetables. LPA L. Hall collected a weekly menu during visit.

On the allegation staff put resident to bed at 5pm. S2 stated that some residents sit in common area to watch television until they are tired, but there are residents that do not leave the room so bed times vary. Resident 1 (R1) stated during interview she goes to bed when she is ready, but it does quiet down in the facility around 7PM.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2