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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201025
Report Date: 10/21/2021
Date Signed: 10/21/2021 02:48:05 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
10/14/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211014172537
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: 37DATE:
10/21/2021
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Divine Fernandez, Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility has pests
Facility not maintained clean and sanitary
INVESTIGATION FINDINGS:
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On 10/21/21 at 12:20PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint investigation. LPA met with Executive Director (ED) and explained the purpose of the visit. LPA conducted interviews, gathered information relevant to the allegations and delivered the findings to ED.

Allegation: Facility has pests
Investigation Finding: Substantiated
During investigation, resident (R1) confirmed with LPA that he saw cockroaches in the dining area on 10/19/21. He stated he has witnessed cockroaches in the dining area in September 2021 as well. ADM confirmed with LPA that they have contracted with pest control company to resolve the pest issue to no avail because the cockroaches keep coming back. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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-20211014172537
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: 10/21/2021
NARRATIVE
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Allegation: Facility not maintained clean and sanitary
Investigation Finding: Substantiated
During visit, LPA along with ED toured the facility including but not limited to residents' bedrooms, bathrooms, kitchen area, dining and living room areas. LPA inspected residents' bedrooms and bathrooms Rms# 30, 32, 33, 46, 36. LPA observed fecal matter on resident's bath chair in Rm# 36, bathroom floors in Rms 31 & 46 (Jack & Jill bathroom) were observed with urine and fecal stains. The preponderance of evidence has been met. Thus, this allegation is subtantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20211014172537
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: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2021
Section Cited
CCR
80087(a)(1)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.(1) The licensee shall take measures to keep the facility free of flies and other insects.
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Administrator agreed to submit to CCLD on or before POC due date copy of new pest control company's scheduled contract work and invoice to resolve facility's pest issue.
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This requirement was not met as evidenced by R1 confirming pests are present in the dining area on several occasions which posed a potential health & safety risk to residents in care.
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Type B
11/08/2021
Section Cited
CCR
87303(a)(1)
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(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.(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition
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Administrator agreed to submit to CCLD on or before POC due date a copy of invoice for cleaning and sanitation by a professional company of all carpeted areas such as hallways, dining, residents' rooms, etc.
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This requirement was not met as evidenced by observation of fecal matter by LPA in Rm#36 and unclean bathrooms in Rms#32/46 which posed a potential health & safety risk to residents 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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC9099 (FAS) - (06/04)
Page: 3 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
10/14/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211014172537

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: 37DATE:
10/21/2021
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Divine Fernandez, Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Uncleared staff working in the facility
Staff forces residents to take medications
INVESTIGATION FINDINGS:
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On 10/21/21 at 12:20PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint investigation. LPA met with Executive Director (ED) and explained the purpose of the visit. LPA conducted interviews, gathered information relevant to the allegations and delivered the findings to ED.

Allegation: Uncleared staff working in the facility
Investigation Finding: Unsubstantiated
Review of records by LPA D Panlilio show facility was assessed a civil penalty by LPA A O'Hollaren on 09/24/21 for uncleared staff/non association to facility in relation to Complaint control number 15-AS-20210924145312. Facility corrected this deficiency on 10/08/21 and associated the fingerprint cleared staff (S1, S2 & S3). LPA observed the associated staff (S1, S2 & S3) are listed in the CCLD database on 10/14/21 with finger print clearance.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20211014172537
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: 10/21/2021
NARRATIVE
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Allegation: Staff forces residents to take medication
Investigation Finding: Unsubstantiated
During visit, LPA interviewed 3 residents (R2, R3, R4). Residents confirmed they receive their medications 3 or 4 times a day directly from the Med Techs. R2 stated to LPA that she has medications prescribed by her doctor that needs to be crushed. She stated she takes the crushed medications with apple sauce because they taste bitter. Residents stated Med Techs or caregivers do not camouflage their medications. Residents interviewed confirmed with LPA that they are not forced to take their medications by Med Techs or caregivers. They stated they take their medications from the cup given by the Med Tech on a daily basis. Med Tech (MT) told LPA that they directly administer the medications to the residents and keep an initialled medication administration record (MARs) on file for each residents' medication dosages and schedules for intake.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are unsubstantiated.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5