019201025-1-19-2024-15-AS-YFLS-D2VUGN-20240228143437

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201025
Report Date: 01/19/2024
Date Signed: 01/19/2024 02:57:24 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
01/11/2024 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20240111151424

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: 54	DATE:	01/19/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Divina Fernandez, Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff does not ensure resident's hygiene needs are being met.
Staff does not ensure resident's room is kept clean.
Staff does not ensure facility is properly sanitized.

INVESTIGATION FINDINGS:

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On 1/19/24 at 12:00 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Divina Fernandez, Administrator and explained the purpose of the visit.

During the course of investigation, LPA interviewed the reporting party (RP) and S1. LPA reviewed the facility’s staffing schedule and shower log. LPA also toured the facility.

Staff does not ensure resident's hygiene needs are being met: RP stated that “hardly ever gets a shower.” Review of the shower log documented that the RP often refuses her showers (about 50% of the time) but is receiving a shower at least weekly.

***report continues on LIC 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

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-20240111151424

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: 01/19/2024

NARRATIVE

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***report continues from LIC9099***

Staff does not ensure resident's room is kept clean: S1 stated that the facility has a housekeeper on the day and PM shifts and that rooms are cleaned once to twice a week and as needed. LPA observed all the residents’ rooms to be clean and free of any odors. The staff schedule also included the housekeeping staff.

Staff does not ensure facility is properly sanitized: S1 stated the facility gets a deep cleaning (carpets cleaned and furniture sanitized) every 3 – 4 months. The most recent deep cleaning was on 1/14 and 1/15, 2024

This agency has investigated the allegation that staff does not ensure resident's hygiene needs are being met, staff does not ensure resident's room is kept clean and staff does not ensure facility is properly sanitized. staff did not provide adequate meal service to a resident. We have found that the complaint was unsubstantiated. 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.

Exit interview conducted, a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC9099 (FAS) - (06/04)

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