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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201025
Report Date: 06/09/2022
Date Signed: 06/09/2022 04:59:59 PM


Document Has Been Signed on 06/09/2022 04:59 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: 50DATE:
06/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Divina Fernandez, AdministratorTIME COMPLETED:
05:13 PM
NARRATIVE
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On 6/9/2022 at 4:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Administrator, Divina Fernandez.

While LPA was at the facility for another visit, LPA observed the following deficiency:

At around 2:20PM, LPA observed a staff left medication unattended while residents were walking around. A staff was preparing medications right outside the medication room and left the medication when LPA arrived at the facility. Staff did not lock up medication prior to helping LPA and visitor. LPA observed two residents passing by the unlocked tray of medication when staff was assisting LPA and visitor.

The deficiency was observed (see LIC 809D) 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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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 06/09/2022 04:59 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: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited

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Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible...
This requirement is not met as evidence by:
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Based on observation, licensee did not comply with the section cited above by having unlocked medication which poses an immediate health and safety risk to the 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
LIC809 (FAS) - (06/04)
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