019201025-7-21-2023-15-AS-KHOS-CVKLYD-20230911091011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201025
Report Date: 07/21/2023
Date Signed: 07/21/2023 06:14:20 PM

Substantiated

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-20220218093018

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:	11:00 AM
MET WITH:	Divine Fernandez, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Untrained staff providing care to residents

INVESTIGATION FINDINGS:

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On 7/21/2023 at 11:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Administrator, Divine Fernandez and explained the purpose of the visit.

During the course of investigation, LPA interviewed complainant. LPA reviewed and obtained documents (staff initial training, CPR, First Aid, medication training, and dementia training). After reviewing a sample of staff training, LPA observed majority of the staff did not have required annual training completed in 2021 and part of 2022.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.

Substantiated

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-20220218093018

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/11/2023 Section Cited HSC 1569.625(b)(2)	1 2 3 4 5 6 7	Staff training; legislative findings; contents. In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training...	1 2 3 4 5 6 7	Administrator has agreed to create a written plan to obtain current annual training for all staff. Administrator will submit plan to CCLD by POC date.
	8 9 10 11 12 13 14	This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not completing annual training for staff which poses a potential health and safety risk to the 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.

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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

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