019201025-1-19-2024-15-AS-YFLS-D2VUEF-20240228143102

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201025
Report Date: 01/19/2024
Date Signed: 01/19/2024 02:58:27 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-20240111091742

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:			TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not provide adequate meal service to a resident
Staff are mistreating a resident while in care

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 also reviewed the facility’s staffing schedule.

Staff did not provide adequate meal service to a resident: RP reported that she was getting ready to go out of the facility to an appointment early in the morning and didn’t receive her breakfast tray service. RP further stated that before she left for her appointment staff did offer her breakfast, but she refused.

***report continues on LIC9099C***

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-20240111091742

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***

LPA observed the lunch service at the facility where trays of food were being prepared for room service. S1 stated that each caregiver has a list of the residents getting tray service. The RP is on permanent tray service as she does not like to eat in the dining room and this incident was the only time she missed her tray service.

Staff are mistreating a resident while in care: RP reported that she did not like one of the caregivers assigned to her and requested a change. She is currently happy with the caregiver.

This agency has investigated the allegation that staff did not provide adequate meal service to a resident

and staff are mistreating a resident while in care. 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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