015601364-4-20-2022-15-AS-KHOS-CEGJQD-20220516071458

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601364
Report Date: 04/20/2022
Date Signed: 04/20/2022 03:23:50 PM

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
10/02/2020 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20201002150036

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:	04/20/2022
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Divina Fernandez, Administrator		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff limit resident's visitation

Staff do not safeguard resident's personal items

Resident does not have adequate linens

Staff do not meet resident's hygiene needs

Staff do not ensure that resident wears weather appropriate clothing

INVESTIGATION FINDINGS:

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On 4/20/2022 at 11:40AM, Licensing Program Analyst (LPA), L. Hall 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 D. Panlilio collected documents. On the allegation staff limited resident’s visitation. PIN-20-23-ASC dated 6/26/20 indicates visits were to be scheduled and limited. Therefore, staff was following guidance to limit visits.

On the allegation staff do not safeguard resident’s personal items. LPA toured facility and spoke with five (5) residents. Residents states that they have not lost or missed any personal items.

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: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

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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Control Number 15-AS-20201002150036

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: 04/20/2022

NARRATIVE

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Continued from LIC9099.

LPA L. Hall reviewed five (5) resident files and two (2) of five (5) had the personal safeguard in the file.

On the allegation residents do not have adequate linens. LPA observed top and bottom sheet, pillow, and blanket on each bed. The linen did not match in color, but it was clean. The residents stated that the linen is changed weekly if not more. If a resident ask for clean linen it is granted. LPA L. Hall obtained laundry schedule which indicated laundry is done once a week. The housekeeping schedule indicated rooms are cleaned twice a week. S3 stated that if resident has an accident or there is a spill the space is cleaned at the time of occurrence.

On the allegation staff do not meet resident's hygiene needs. LPA L. Hall toured facility and observed the residents, their rooms, shared bathroom, kitchen, and common areas. LPA did not smell any order at the facility or coming from the residents. The residents LPA interviewed stated they are bathed twice a week.

On the allegation staff do not ensure that resident wears weather appropriate clothing. S1 stated that family provides clothing for the residents and most residents gets assistance with dressing. LPA observed residents with appropriate clothing for the day.

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: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

LIC9099 (FAS) - (06/04)

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