019201025-6-7-2024-15-AS-BFOG-D66TZ5-20240612150944

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201025
Report Date: 06/07/2024
Date Signed: 06/07/2024 05:51:46 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
06/03/2024 and conducted by Evaluator Lori Alexander-Washington

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240603103355

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: 60	DATE:	06/07/2024
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Steve Comtiag, Resident Care Director		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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1. Staff did not provide a comfortable environment for resident
2. Resident smokes while using oxygen

INVESTIGATION FINDINGS:

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On 06/07/2024, at 1:25 PM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct initial 10-day complaint visit for the above allegations. LPA met with Resident Care Director (RCD)/LVN, Steve Comtiag and explained the reason for the visit.

Allegations: 1. Staff did not provide a comfortable environment for resident, 2. Resident smokes while using oxygen

LPA reviewed copies of Physician's Reports and Doctor's Orders

LIC809-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

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 4

Control Number 15-AS-20240603103355

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LINCOLN VILLA	FACILITY NUMBER: 019201025
	VISIT DATE: 06/07/2024

NARRATIVE

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LIC809-C Continued...

Allegation: Staff did not provide a comfortable environment for resident.
Substantiated.

On 06/06/2024 LPA spoke to RP who stated that R1 is wandering at night and early in the morning disturbing other residents. RP stated that R1 opened their bedroom door and came into their room. RP stated that the staff said that they couldn't do anything and to lock their doors. LPA interviewed S1 that stated that R1 has Dementia and they are aware of R1 walking at night, going into other residents' rooms, banging on the doors and the behavior. LPA interviewed S2 that stated that R1's behavior changed when they discontinued the medication that was helping the insomina and resident's behavior. S2 stated that R1's son wanted the medication stopped because R1 was gaining weight and was eating more food.

Allegation: Resident smokes while using oxygen.
Substantiated.

On 06/06/2024 LPA spoke with RP who stated that R2 was smoking cigarettes in their own bedroom while they have oxygen in R2's bedroom. RP stated that R2 shares room with another resident (R3). RP stated that R2 came to them asking for a cigarette lighter. RP stated that R2's room is across the hall. RP stated that they do not feel safe due to R2 smoking and also having a lighter in the their possession while oxygen is in use in the bedroom. LPA interviewed S1 that stated about 2-3 weeks ago, the caregivers did find cigarettes and a lighter in R2's bedroom. S1 stated that one of the Med Techs saw a cup and smelled a cigarette and that is when they found the cigarette. S1 stated that on that day R2 wasn't on their baseline and seemed confused. S1 stated that R2 was transported to the hospital for shortness of breath. S1 stated that R2 returned back to the facility with a hospice order. LPA interviewed S2 that stated that the incident was discussed by the supervisor and that staff is suppose to monitor that R2 doesn't get any more cigarettes and lighters.

LIC9099-C Continued...

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20240603103355

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LINCOLN VILLA	FACILITY NUMBER: 019201025
	VISIT DATE: 06/07/2024

NARRATIVE

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LIC9099-C Continued...

S2 stated that R2 can smoke in the courtyard area which is designated for smoking. S2 stated that when R2 wants to smoke they have to come to the Med Tech room and hand over the portable oxygen and then the Med Techs will give R2 a cigarette and lighter. S2 stated that there is always a caregiver with R2 when they smoke a cigarette in smoking area. LPA called and interviewed S3 that stated R2 does not smoke in their room and that they have not seen any cigarettes.

Based on LPA's observations, and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations 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 Administrator. Appeal rights and copy of this report was provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20240603103355

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LINCOLN VILLA	FACILITY NUMBER: 019201025
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/14/2024 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all..shall have...personal rights: (2) To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agree to write up a plan to mitigate this type of issue and submit to CCLD by POC due date.
	8 9 10 11 12 13 14	Based on interviews andrecord review, the licensee did not comply with the section cited above by not having which poses an immediate health, safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 06/14/2024 Section Cited CCR 87618(b)(3)(C)	1 2 3 4 5 6 7	87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b)...(3) Ensuring that the use of oxygen..:(C) Smoking shall be prohibited where oxygen is in use. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agrees to write up a plan to mitigate this issue and submit to CCLD by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the section cited above by not having cigarettes and lighters inaccessible to R2 while oxygen in use inside which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC9099 (FAS) - (06/04)

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