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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201025
Report Date: 09/28/2021
Date Signed: 09/28/2021 03:05:05 PM



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
09/24/2021 and conducted by Evaluator Allison O'Hollaren
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210924145312
FACILITY NAME:LINCOLN VILLAFACILITY NUMBER:
019201025
ADMINISTRATOR:FERNANDEZ, DIVINAFACILITY TYPE:
740
ADDRESS:41040 LINCOLN STREETTELEPHONE:
(510) 656-4373
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:76CENSUS: 36DATE:
09/28/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Divine FernandezTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility does not have an activities director
Uncleared staff is present in the facility
INVESTIGATION FINDINGS:
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On 09/28/2021 at approximately 9:30am Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to conduct a 10-day initial complaint opening. LPA met with Administrator Divine Fernandez and explained the purpose of the visit.

During visit LPA interviewed Administrator, two staff, and three residents. LPA reviewed staff roster, staff schedule, resident roster, physician reports, and activity schedule.

During the course of the investigation, Administrator Divine Fernandez, two staff, and three residents confirmed the facility has not had an activities director since 2019.

Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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 5
Control Number 15-AS-20210924145312
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: 09/28/2021
NARRATIVE
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Based on LPA’s interviews and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

The following deficiency was observed (See LIC 809D) and cited from the California Code of Regulations, Title 22 and California health and safety code. Failure to correct the deficiency may result in civil penalties.

During visit, Administrator Divine Fernandez confirmed that Staff S1 has been working at the facility for around nine months, Staff S2 has been working at the facility for around nine months, and Staff S3 has worked at the facility for around one year and six months. S1, S2, and S3 do not have fingerprint clearance.

The Department has conducted an investigation into the above allegation and based upon observations, records review, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation was found to be SUBSTANTIATED.

Civil penalties assessed in the amount of $1500.00 for unauthorized staff working at the facility without fingerprint clearance.

Type A Deficiency cited per California Code of Regulations, Title 22, and listed on LIC 9099-D. Failure to submit Proof of Correction (POC) by Plan of Correction date may result in civil penalties.

LIC9099, LIC9099-C, LIC9099-D, Appeal Rights, and LIC 421CB provided and exit interview conducted with Administrator.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 15-AS-20210924145312
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2021
Section Cited
CCR
87355 87355(e)
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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
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Staff S3 will leave facility immediately. Administrator will review staff roster and ensure all staff are fingerprint cleared and associated to facilityand submit self-certification by POC date.
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(1) Obtain a California clearance or a criminal record exemption as required by the Department or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
(3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. This requirement was not met as evidence by: Based on observation, interview, and record review, the licensee did not comply with the section cited above. Three staff are working at the facility without fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
10/11/2021
Section Cited
CCR
87219(f)
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87219 Planned Activities (f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given
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By POC date, Administrator agrees to send CCL an updated LIC500 with Activities Director by fax or email.
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such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. The program of activities shall be written, planned in advance, kept up-to-date, and made available to all residents. The responsible employee shall have had at least one year of experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers. This requirement was not met as evidenced by: Based on interview and record review the licensee did not comply with the section cited above. Administrator Divine Fernandez, two staff, and three residents confirmed the facility does not have an activities director which poses a potential health, safety or personal 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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
09/24/2021 and conducted by Evaluator Allison O'Hollaren
COMPLAINT CONTROL NUMBER: 15-AS-20210924145312

FACILITY NAME:LINCOLN VILLAFACILITY NUMBER:
019201025
ADMINISTRATOR:FERNANDEZ, DIVINAFACILITY TYPE:
740
ADDRESS:41040 LINCOLN STREETTELEPHONE:
(510) 656-4373
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:76CENSUS: 36DATE:
09/28/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Divine FernandezTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility does not provide activities for residents
INVESTIGATION FINDINGS:
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On 09/28/2021 at approximately 9:30am Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to conduct a 10-day initial complaint opening. LPA met with Administrator Divine Fernandez and explained the purpose of the visit.

During visit LPA interviewed Administrator, two staff, and three residents. LPA reviewed staff roster, staff schedule, resident roster, physician reports, and activity schedule.

During the course of the investigation, Administrator Divine Fernandez, two staff, and two residents confirmed the facility provides activities to the residents.

Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20210924145312
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: 09/28/2021
NARRATIVE
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The Department has investigated this allegation and based upon interviews conducted and records reviewed, the allegation is found to be unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation has occurred.

Exit interview conducted with Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'HollarenTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5