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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601364
Report Date: 11/22/2022
Date Signed: 11/22/2022 01:59:37 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
02/09/2021 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20210209092034
FACILITY NAME:LINCOLN VILLAFACILITY NUMBER:
015601364
ADMINISTRATOR:BROWN, DEBORAFACILITY TYPE:
740
ADDRESS:41040 LINCOLN AVENUETELEPHONE:
(510) 656-4373
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:0CENSUS: 0DATE:
11/22/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Divine Fernandez, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Resident not provided with appropriate foods for his diet
Resident left in soiled diapers multiple times
Resident's medications were missing
INVESTIGATION FINDINGS:
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On 11/22/22.at 1:45 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver the findings for the above allegations. LPA met with Divine Fernandez, Administrator and explained the purpose of the visit.

During the course of investigation, LPA G. Luk interviewed: the complainant (RP), 4 residents, 2 staff and 2 witnesses. LPA G. Luk toured facility including the kitchen.

Based on interviews residents were receiving proper food for their dietary needs. R4 stated that the food is good. W2 stated her family member is on a low sodium diet and that he receives appropriate food items most of the time. LPA G. Luk observed special diet postings for residents in the kitchen. S2 stated she changes residents diets after notification from the med room.

***Report continues on LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
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-20210209092034
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: 11/22/2022
NARRATIVE
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***Report continues from LIC9099***

Residents reported that their diapers are changed on a regular basis and as needed.

S1 stated that the medications are locked and properly stored at all times and that unused medications are returned to families when a resident moves out. LPA was not able to obtain a medication list for R1 and could not determine if medications were missing at the time of R1's discharge from the Facility

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2