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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201025
Report Date: 12/04/2024
Date Signed: 12/04/2024 06:38:48 PM

Document Has Been Signed on 12/04/2024 06:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LINCOLN VILLAFACILITY NUMBER:
019201025
ADMINISTRATOR/
DIRECTOR:		FERNANDEZ, DIVINAFACILITY TYPE:
740
ADDRESS:41040 LINCOLN STREETTELEPHONE:
(510) 656-4373
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 76CENSUS: 65DATE:
12/04/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Divina Fernandez/AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Delmundo conducted a case management inspection to ensure the facility is in compliance with applicable statutes and regulations and ensure the health and safety of residents. LPA met with Divina Fernandez, administrator (ADM), and informed the reason for visit.

LPA conducted a tour of the physical plant with the ADM. Food supplies were checked and observed good for 2 days of perishables and 7 days of non-perishables.

During the visit, the LPA conducted interviews with residents, staff and the administrator. Licensees are not on-site and not available for interview.

LPA reviewed staff and resident files and checked the medication room.

LPA observed the following:


-at 2:45 pm, garden shears and rake in a broken storage in the courtyard.
-at 2:52 pm to 3:15 pm, peritoneal cleanser, shaving cream in the residents rooms.
-at 3:05 pm, unlocked housekeeping room where cleaning supplies are kept.
-strong smell of urine in the hallway and activity area.

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with ADM.

An exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and a copy of the report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 12/04/2024 06:38 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/04/2024 at 05:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LINCOLN VILLA
FACILITY NUMBER: 019201025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2024
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Administrator had the items locked.

In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 12/05/24.
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-This requirement is not met as evidenced by:

-Based on observation, the licensee did not comply with the section above in unlocked peritoneal cleanser and shaving cream which pose an immediate health and safety risks to persons in care.
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Type A
12/05/2024
Section Cited
CCR87309(a)

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87309 Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

-This requirement is not met as evidenced by
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Administrator had the shears, rake and housekeeping room locked.

In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 12/05/24.
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-Based on observation, the licensee did not comply with the section above in broken storage where rake and garden shears are kept and housekeeping room unlocked which pose an immediate health and safety risks to persons 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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/04/2024 06:38 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 12/04/2024 at 06:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LINCOLN VILLA
FACILITY NUMBER: 019201025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Administrator stated she'll have the carpet deep cleaned and submit proof by 12/18/24.
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-This requirement is not met as evidenced by:

-Based on observation, the licensee did not comply with the section above in strong smell of urine in the hallway and activity area which pose a potential rights risk to persons 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.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
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