019201025-2-24-2021-15-AS-GLUK-BYK3RN-20210224172903

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019201025
Report Date: 02/24/2021
Date Signed: 02/24/2021 05:29:17 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 VILLA		FACILITY NUMBER:	019201025
ADMINISTRATOR:	FERNANDEZ, DIVINA		FACILITY TYPE:	740
ADDRESS:	41040 LINCOLN STREET		TELEPHONE:	(510) 656-4373
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	76	CENSUS: 36	DATE:	02/24/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Divina Fernandez, Administrator		TIME COMPLETED:	05:00 PM

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On 2/24/2021 at 1:30PM, Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit Pre-Licensing inspection via FaceTime due to shelter in place directed by the Governor. LPA spoke with Administrator, Divina Fernandez. The facility's fire clearance was approved for 76 bedridden residents.

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. Resident's bedrooms are fully furnished with bed, dresser, night stand, and chair. Resident's bathrooms were equipped with grab bars and non-skid mats/material. LPA observed lighting in all rooms. LPA observed facility had a 7-day of non-perishable and 2-day perishable food supplies. Refrigerator temperature was read at 30 degree F and freezer temperature was read at -10 degree F. Medication carts and medication room were locked during inspection. Smoke detectors are interconnected with sprinkler system. First aid kit is complete. LPA advised Administrator that hot water temperature should be maintained between 105 degrees F and 120 degrees F. Indoor and outdoor passageways were free of obstruction. Fire extinguisher was observed to be full and last serviced on 12/3/2020.

The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB):

1. LPA observed common areas of facility does not have carbon monoxide detectors. Common areas of the facility should have carbon monoxide detectors.

2. LPA observed shared bathrooms did not have paper towels available.

Licensee/applicant will submit proof of corrections to CCLD on/before 3/12/2021.

LPA conducted Component III with Administrator during Tele-visit. LPA presented Component III Power Point and discussed the regulations embodied in the presentation. Exit interview conducted and a copy of this report will be emailed.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (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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