019201025-5-30-2025-15-AS-KHOS-DHQSKD-20250617135633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201025
Report Date: 05/30/2025
Date Signed: 05/30/2025 03:01:18 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
03/25/2025 and conducted by Evaluator Luisa Fontanilla

COMPLAINT CONTROL NUMBER: 15-AS-20250325120038

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: 68	DATE:	05/30/2025
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Divina Fernandez		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not prevent a resident from hitting another resident

INVESTIGATION FINDINGS:

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On 05/30/2025, at 2:30 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: Staff did not prevent a resident from hitting another resident

During the course of investigation, LPAs Patricia Manalo and Luisa Fontanilla conducted a 10-day visit and interviewed Administrator (ADM), Staff 1 (S1), Resident 1 (R1), and Resident 2 (R2) on 03/26/2025. LPAs obtained and reviewed documents such as Appraisal Needs and Services Plan, Identification and Emergency Information, Police Report, Physician’s Report, Medication room (Medroom) Daily Communication Log for R1 and R2, and Unusual Incident Report.

Continue to LIC9099-C...

Unsubstantiated

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)

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Control Number 15-AS-20250325120038

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...

Interviews with S1 and ADM revealed that R2 went into R1’s room to get items such as food and a cup. According to Medroom Daily Communication Log dated 03/22/2025, R1 went to the front desk and told staff that R2 went to R1’s room, grabbed R1’s cup, and R2 hit R1 on the left side of the face. When staff interviewed R2 about the incident, R2 stated that they wanted the cup from R1’s room. The log also stated that when police arrived, resident refused to go to the hospital.

LPAs interviewed R1 and stated that R2 hit R1 in R1’s room. R1 stated that R2 took R1’s food and hit R1’s left side of the head with R2’s hand. Then, R1 proceeded to go to the Med Room area to tell S1 what had happened. However, when R2 was interviewed, R2 does not recall going into R1’s room or that the incident occurred on 03/22/2025.

After the incident, staff assessed R1 for injuries. Staff did not observe any bruising or swelling. R1 was monitored from 03/22/2025 to 03/25/2025 and still did not find any bruising or swelling.

A review of R2’s medical assessment indicates R2 is ambulatory. There is no record observed that shows R2 having aggressive behavior. Staff interviewed denied witnessing R2 being aggressive to staff or any other resident.

A copy of the police report was obtained. Police investigation did not indicate any injuries that occurred during the incident, but that staff will keep the residents separated.

Based on record reviews and interviews conducted, the above allegation is unsubstantiated.

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

There is no deficiency noted. Exit interview conducted and a 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)

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