019201025-8-8-2023-15-AS-KHOS-CUWQL4-20230821121518

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201025
Report Date: 08/08/2023
Date Signed: 08/08/2023 03:01:51 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
03/09/2023 and conducted by Evaluator Liridon Fici

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230309143126

FACILITY NAME:	LINCOLN VILLA		FACILITY NUMBER:	019201025
ADMINISTRATOR:	FERNANDEZ, DIVINA		FACILITY TYPE:	740
ADDRESS:	41040 LINCOLN STREET		TELEPHONE:	(510) 656-4373
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	76	CENSUS: 59	DATE:	08/08/2023
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Divina, Fernandez, Administrator		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Staff do not ensure meals are made available to resident.
Staff did not provide adequate care and supervision resulting in resident losing weight.
Staff prevented resident from having visitors.
Staff prevented resident from using assistive devices.

INVESTIGATION FINDINGS:

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On 8/8/2023 at 9:50 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a subsequent complaint investigation visit and to deliver findings on the above allegations. LPA was greeted by Fernandez, Divina, Administrator (ADM) and explained the purpose of the visit.

During visit, LPA interviewed two (2) staff at 10:40 AM, and four (4) residents in care at 12:35 PM.

During the course of the investigation, LPA interviewed three (3) staff members and obtained the following documents from ADM, Residents roster, staff rosters with contact information, food menu, residents visitors log (January and February 2023), Pre- appraisal, Admission agreement, Functional capability form, Needs and Services plans, Care notes (January, February, and March 2023), and Physicians Reports of a sample of 6 of 6 residents.

Continue on Lic9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230309143126

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LINCOLN VILLA	FACILITY NUMBER: 019201025
	VISIT DATE: 08/08/2023

NARRATIVE

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Continue from Lic9099

Based on interviews conducted, it was alleged that, staff do not ensure meals are made available to resident. LPA confirmed with five (5) staff members and all 5 staff members stated that meals are given to all residents, and room service is also available for residents if residents want to eat in their rooms. LPA confirmed with staff that other food options are given to residents if a resident does not like what is on the food menu for that day. R1, R2, R3, and R4 stated plenty of food is given to residents along with liquids. LPA obtained a food menu for January thought March 2023.

Based on interviews conducted, it was alleged that, staff did not provide adequate care and supervision resulting in residents losing weight. LPA confirmed with five (5) staff members, and all 5 staff members stated that residents’ vitals are monitored and checked. A communication is filled out and submitted to the nurse to advise residents’ doctor. Residents PCP, doctors, nurses, and residents’ representative are notified regarding weight loss.

Based on interviews conducted, it was alleged that, Staff prevented resident from having visitors. LPA confirmed with five (5) staff members, and all 5 staff members stated that visits are allowed to visit residents. LPA obtained a visitors log from December 2022- February 2023. R1-R4 stated that visits are allowed, and staff allows visitors to come and visit the residents at any time. All visitors have to sign in and out before entering the facility and leaving the facility.

Based on interview conducted, Staff prevented resident from using assistive devices. LPA confirmed with five (5) staff members and all 5 staff members stated that residents’ use their assistive device when residents need to. S2 stated to LPA that staff will assist resident sometimes when a resident is walking around the facility with their assistive device. LPA observed residents walking around the facility with assistive devices during visit on 3/17/2023.

Based on Interviews, and record review conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with ADM, and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

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