<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201025
Report Date: 02/12/2025
Date Signed: 02/12/2025 06:31:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
02/07/2025 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250207102224
FACILITY NAME:LINCOLN VILLAFACILITY NUMBER:
019201025
ADMINISTRATOR:FERNANDEZ, DIVINAFACILITY TYPE:
740
ADDRESS:41040 LINCOLN STREETTELEPHONE:
(510) 656-4373
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:76CENSUS: 66DATE:
02/12/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Divine Fernandez, AdministratorTIME COMPLETED:
06:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee did not provide resident of monthly fees upon admission.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/12/2025, at 11:45 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct initial 10-day complaint visit and delivery for the above allegation. LPA met with Administrator (ADM), Divine Fernandez and Resident Care Director (RCD)/LVN, Steve Comtiag and explained the reason for the visit.

LPA reviewed copies of R1's-R5's Admissions Agreements, Physician's Reports, Face Sheets, Identification and Emergency Information forms, PIN 24-13-CCLD (dated 11/18/24), Medi-Cal Assisted Living Waiver Program (ALW) Increased Bill Rates (Eff. 01/01/24), and R1's Bill Invoice (12/23 thru 02/25).

LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
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 5
Control Number 15-AS-20250207102224
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LINCOLN VILLA
FACILITY NUMBER: 019201025
VISIT DATE: 02/12/2025
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
LIC9099-C (Page 2)

Allegation: Licensee did not provide resident of monthly fees upon admission.
Finding: Substantiated

On 02/12/2025 LPA interviewed W (W1). W1 stated that Resident (R) R1 never received any documents on the payments and due dates. W1 stated that R1 became aware of unpaid payments in mid Oct/Nov '24. LPA interviewed Staff (S). S1 and S2 stated that billing invoices were mailed monthly to R1's home address on file and that they also hand delivered a copy to R1 at the facility. S1 and S2 stated that the mailed billing statements were being returned back undelivered. LPA interviewed R1 that stated that they never received any billing statements while at the facility. R1 stated that they do not remember receiving billing invoices and that they have not received anything monthly directly from the facility. R1 stated that the address on file is where they lived 2 years ago and that their family does not live at that address anymore.

Based on LPA's observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted with Divine Fernandez. Appeal rights and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250207102224
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LINCOLN VILLA
FACILITY NUMBER: 019201025
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/19/2025
Section Cited
HSC
1569.884
1
2
3
4
5
6
7
§1569.884 Contents of residential care facility admission agreements. The admission agreement shall include all of the following:

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to read the regulation and self-certify that they read and understand the regulation moving forward. In addition, review, train and complete an audit of all resident's admission agreements including but not limited all comprehensive details with fees, monthly fees, billing and payment procedures . Send self-certifications to CCLD by POC due date.
8
9
10
11
12
13
14
Based on interviews and record reviews, the licensee did not comply with the section cited above by not providing in the admission agreement including but not limited an comprehensive description of fees, services, monthly fee for room and board which poses an immediate health, safety and personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
02/07/2025 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250207102224

FACILITY NAME:LINCOLN VILLAFACILITY NUMBER:
019201025
ADMINISTRATOR:FERNANDEZ, DIVINAFACILITY TYPE:
740
ADDRESS:41040 LINCOLN STREETTELEPHONE:
(510) 656-4373
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:76CENSUS: 66DATE:
02/12/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Divine Fernandez, AdministratorTIME COMPLETED:
06:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee did not obtain signature of resident’s representative on admission agreement.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/12/2025, at 11:45 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct initial 10-day complaint visit and delivery for the above allegation. LPA met with Administrator (ADM), Divine Fernandez and Resident Care Director (RCD)/LVN, Steve Comtiag and explained the reason for the visit.

LPA reviewed copies of R1's-R5's Admissions Agreements, Physician's Reports, Face Sheets, Identification and Emergency Information forms, PIN 24-13-CCLD (dated 11/18/24), Medi-Cal Assisted Living Waiver Program (ALW) Increased Bill Rates (Eff. 01/01/24), R1's Bill Invoice (12/23 thru 02/25).

LIC9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250207102224
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LINCOLN VILLA
FACILITY NUMBER: 019201025
VISIT DATE: 02/12/2025
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
LIC9099-C (Page 2)

Allegation: Licensee did not obtain signature of resident’s representative on admission agreement.
Finding: Unsubstantiated

On 02/12/2025 LPA interviewed W (W1). W1 stated that Resident (R1) does not have an Responsible Party and that R1 is his own self responsible party financially. LPA interviewed R1 and R1 stated that they are the only person that signed the admission agreement. LPA reviewed R1's admission agreement documents and all documents obtained included R1's signatures.

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

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5