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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201025
Report Date: 04/20/2022
Date Signed: 04/20/2022 03:51:55 PM


Document Has Been Signed on 04/20/2022 03:51 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:FERNANDEZ, DIVINAFACILITY TYPE:
740
ADDRESS:41040 LINCOLN STREETTELEPHONE:
(510) 656-4373
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:76CENSUS: 49DATE:
04/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Divina Fernandez, AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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On 4/20/2022 at 3:25PM Licensing Program Analyst (LPA) L. Hall and L. Holmes arrived unannounced to conduct a Case Management. LPA met with Davina Fernandez, Administrator.

When LPA L. Hall delivered complaint findings (15-AS-20201002150036) on 4/20/2022, LPA reviewed R2's file and observed facility did not request an exemption before admitting a resident with a restricted health condition. S1 stated that the facility did not request an exemption.

The following deficiency was observed:

- On 4/20/2022 LPA reviewed R2's file and did not observed an exemption for a restricted health condition.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/20/2022 03:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2022
Section Cited

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87611 (a) Prior to accepting or retaining a resident with an allowable health condition... Colostomy/Ileostomy.. shall obtain Department approval: This requirement was not met as evidence by:
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Based up LPA's record review licensee did not comply wit the section cited above by requesting an exemption for a restricted health condition, which poses a potential health and safety risk to person 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
LIC809 (FAS) - (06/04)
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