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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201025
Report Date: 05/30/2025
Date Signed: 05/30/2025 02:55:46 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
04/17/2025 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250417082431
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: 68DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Divina Fernandez, Administrator TIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Facility staff are not following proper reporting requirements
INVESTIGATION FINDINGS:
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On 5/30/2025 at 12:15 PM, Licensing Program Analysts (LPAs) P. Manalo and L. Fontanilla arrived unannounced to deliver finding on the above allegation. LPAs met with Administrator, Divina Fernadez, and explained the purpose of the visit.

Allegation: Facility staff are not following proper reporting requirements

During the course of investigation, LPA P. Manalo conducted a 10-day visit and interviewed Administrator (ADM), Staff 1(S1), and Staff 2 (S2) on 04/17/2025. On 5/30/2025, LPAs interviewed Staff 3 (S3), Staff 4 (S4) and Staff 5 (S5). LPA obtained and reviewed records for Resident 1 (R1) and Resident 2 (R2) such as Appraisal Needs and Services Plan, Individual Service Plan, Physician’s Report, Lic. 500 and Resident Roster.

Continue to LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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 3
Control Number 15-AS-20250417082431
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: 05/30/2025
NARRATIVE
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Continue from LIC9099...

Based on interviews conducted on 04/17/2025 and 05/30/2025, ADM confirmed with LPAs that the facility did not submit an SOC 341 to Ombudsman regarding the incident that occurred on 3/22/2025 between R1 and R2.

All staffs that LPAs interviewed stated that all unusual incidents get verbally reported to the supervisor and then recorded in the communication log. However, staff admitted to not having completed an SOC 341. The above allegation is substantiated.

Based on interviews conducted, 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), is being cited on the attached LIC 9099D.


Exit interview conducted with Fernandez. Appeal rights and copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250417082431
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: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2025
Section Cited
CCR
87211(c)
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Reporting Requirements
(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours...

This requirement is not met by:
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The Administrator agrees to have all staff retrained on the reporting requirements including on how to fill and submit SOC341. Proof of correction will be sent to CCLD by POC Date.
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Based on observation, the licensee did not comply with the section cited above by not reporting to the local ombudsman which poses a potential health and safety risk to residents in care.
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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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3