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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201025
Report Date: 03/20/2025
Date Signed: 03/20/2025 02:08:26 PM

Document Has Been Signed on 03/20/2025 02:08 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
OAKLAND ASC, 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: 68DATE:
03/20/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:13 PM
MET WITH:Divina Fernandez, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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On 03/20/2025 at 1:13 PM, Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen while at the facility for a pre-licensing observed the following deficiencies:
  • At 10:50 AM, LPA observed the Med cart unlocked, and medications were found in Room #3, Room #15, and room #31.
  • At 12:00 PM, LPA observed Lysol Cleaning wipes in Room #26 and shower grease spray, deep cleaning spray in Room #15.

Deficiency is cited from Title 22 California Code of Regulation (see 809D). Failure to submit proof of correction and any repeat violation within twelve-month period may result in additional civil penalties.

Exit interview conducted. Appeal Rights, and copy of this report provided via e-mail.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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 2
Document Has Been Signed on 03/20/2025 02:08 PM - It Cannot Be Edited


Created By: Patricia Manalo On 03/20/2025 at 01:16 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: 03/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2025
Section Cited
CCR
87309(a)

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Storage Space and Access 87309(a)
(a)... disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents...

This requirement does not met by:
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The licensee/ applicant locked the items during the visit. The licensee will have an in-service training with their staff and talk to family members and will send proof to CCLD by POC date.
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Based on observation, the licensee did not comply in having Lysol Cleaning wipes in Room #26 and shower grease spray, deep cleaning spray in Room #15 which poses a potential health and safety risk to the residents in care.
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Type A
03/21/2025
Section Cited
CCR87465(h)(2)

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87465(h)(2) Incidental Medical and Dental Care ...(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement does not met by:
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The licensee/applicant removed the medications from the room during the visit.
The licensee will have an in-service training with their staff and talk to family members and will send proof to CCLD by POC date.
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Based on observation, the licensee did not comply in having the Med cart unlocked, and medications were found in Room #3, Room #15, and room #31.
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2