019201025-7-21-2023-15-AS-KHOS-CVKQ6Y-20230911115420

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201025
Report Date: 07/21/2023
Date Signed: 07/21/2023 06:15:55 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
02/18/2022 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220218145508

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: 58	DATE:	07/21/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Divine Fernandez, Administrator		TIME COMPLETED:	06:20 PM

ALLEGATION(S):

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Staff did not ensure resident had adequate nutrition
Resident suffered from dehydration while in care.
Resident's care needs were not being met.

INVESTIGATION FINDINGS:

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On 7/21/2023 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Administrator, Divine Fernandez.

During the course of investigation, LPA interviewed 3 residents, 2 staff, and 2 witnesses. LPA also obtained and reviewed documents including: facility menu, physician's report, care plan, emergency information, care notes, and home health notes.

Staff did not ensure resident had adequate nutrition
LPA observed facility menu has various food groups which includes carbohydrates, vegetables, meats, and fruits. Interview with residents revealed that facility meals have adequate nutrition.
(Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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-20220218145508

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: 019201025
	VISIT DATE: 07/21/2023

NARRATIVE

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Resident suffered from dehydration while in care.
It was noted on one of the home health visit that R1 had dark amber colored urine and home health nurse instructed on adequate fluid intake for R1. However, from the documents reviewed, there was no incident where R1 suffered dehydration. Interview with staff revealed that R1 did not like facility water and prefers sparkling water. R1's family bought sparkling water to the facility for R1.

Resident's care needs were not being met.
Interview with residents revealed that staff assist residents with ADL (Activities of Daily Living) care. Residents stated that their needs were met. After reviewing facility care notes, LPA observed that R1 sometimes refused ADL care. Interview with W2 revealed that R1 was clean when W2 visited and did not observed R1's hygiene needs not met.

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

Exit interview conducted. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

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