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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201025
Report Date: 07/08/2025
Date Signed: 07/08/2025 02:49:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
04/18/2025 and conducted by Evaluator Patricia Manalo
COMPLAINT CONTROL NUMBER: 15-AS-20250418125431
FACILITY NAME:LINCOLN VILLAFACILITY NUMBER:
019201025
ADMINISTRATOR:FERNANDEZ, DIVINAFACILITY TYPE:
740
ADDRESS:41040 LINCOLN STREETTELEPHONE:
(510) 656-4373
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:0CENSUS: 75DATE:
07/08/2025
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Divina Fernandez, Administrator TIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff confiscated resident's personal items
INVESTIGATION FINDINGS:
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On 07/08/2025, at 1:50 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to deliver findings on the above allegation. LPA met with Administrator, Divine Fernandez, and explained the purpose of the visit.

During the course of the investigation, LPA P. Manalo interviewed Administrator, 4 resident, and 6 staff. LPA obtained the following documents such as Resident Roster, April 2025 Staff Schedule, Staff Contact Information, Residents' Service Plan Report, Physician's Report, Emergency ID Contact Information, Shower Logs For March and April , Shower Schedules, Facility's Medication Policy, and Medication Administration Record (MAR).

It was alleged that staff confiscated resident’s personal items.

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

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
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-20250418125431
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LINCOLN VILLA
FACILITY NUMBER: 019201025
VISIT DATE: 07/08/2025
NARRATIVE
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Continue from LIC9099..

Interview with R1 indicated that staff took R1’s hygiene products from their room that includes prescription items. Interviews with R2, R3, and R4 revealed that staff took belongings such as medications and supplies to place in a locked cabinet in their rooms. R1 confirmed that they received an item back, but not their prescribed item. Interview with Administrator (ADM) on 06/04/2025 revealed there is a facility policy to have a written physician’s order that explains that residents are allowed to have medications stored their room. A review of the facility policy on Medication Storage and Bedside Authorization on 06/04/2025 stated that residents can keep medications at their bedside if there is a written physician’s order that states that the residents need to for their care. However, a review of R1’s physician’s report dated 03/25/2025 showed that R1 is able to store prescription and PRN medications.

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 with Administrator. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250418125431
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LINCOLN VILLA
FACILITY NUMBER: 019201025
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/23/2025
Section Cited
CCR
87468.1(a)(12)
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87468.1(a)(12) Personal Rights of Residents in All Facilities(12)To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money.
This requirement is not met as evidenced by:
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The Administrator agrees to conduct an in-service of residents' personal rights training and send proof to CCLD by POC date.
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Based on interviews, the licensee did not comply with the section cited above when staff removed R1's hygeine and prescription items which poses a potential personal rights risk to person 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: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
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
OAKLAND ASC, 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
04/18/2025 and conducted by Evaluator Patricia Manalo
COMPLAINT CONTROL NUMBER: 15-AS-20250418125431

FACILITY NAME:LINCOLN VILLAFACILITY NUMBER:
019201025
ADMINISTRATOR:FERNANDEZ, DIVINAFACILITY TYPE:
740
ADDRESS:41040 LINCOLN STREETTELEPHONE:
(510) 656-4373
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:0CENSUS: 75DATE:
07/08/2025
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Divina Fernandez, Administrator TIME COMPLETED:
02:50 PM
ALLEGATION(S):
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3
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9
Staff left resident in soiled undergarments for an extended period of time
INVESTIGATION FINDINGS:
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On 07/08/2025, at 1:50 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to deliver findings on the above allegation. LPA met with Administrator, Divine Fernandez, and explained the purpose of the visit.

During the course of the investigation, LPA P. Manalo interviewed Administrator, 4 resident, and 6 staff.
LPA obtained the following documents such as Resident Roster, April 2025 Staff Schedule, Staff Contact Information, Residents' Service Plan Report, Physician's Report, Emergency ID Contact Information, Shower Logs For March and April , Shower Schedules, Facility's Medication Policy, and Medication Administration Record (MAR).

It was alleged that staff left resident in soiled undergarments for an extended period of time.

Continue to LIC9099...

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
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-20250418125431
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LINCOLN VILLA
FACILITY NUMBER: 019201025
VISIT DATE: 07/08/2025
NARRATIVE
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Continue from LIC9099-A...

During the initial visit on 04/23/2025, LPA toured the facility and did not observe any residents smelling of urine or in soiled undergarments. Interview with R1 stated that staff would not change their diapers and leave them soaked. 2 out of the 4 residents revealed that staff would assist them in diaper changes when needed and on their scheduled times. 1 out of the 4 residents interviewed can toilet on their own and stated that they do not need assistance with diaper change. Staff interviews revealed that they would check on the residents during their first round of the shift, every 2 hours after that, and as needed.

Based on interviews and record reviews conducted, the above allegations are unsubstantiated.

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

No deficiencies cited.

Exit interview conducted with Administrator.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5