019201025-8-8-2023-15-AS-KHOS-CUWRVN-20230821132149

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201025
Report Date: 08/08/2023
Date Signed: 08/08/2023 05:34:48 PM

Substantiated

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
05/12/2023 and conducted by Evaluator Liridon Fici

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230512112826

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:	03:05 PM
MET WITH:	Fernandez, Divina- Administrator		TIME COMPLETED:	05:43 PM

ALLEGATION(S):

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Staff did not treat resident with dignity or respect.
Staff did not keep the facility clean and sanitary.
Staff did not keep the facility free from cockroaches.
Staff did not ensure that medications were distributed to residents in a safe manner.

INVESTIGATION FINDINGS:

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On 8/8/2023 at 3:05 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a subsequent complaint investigation visit and to delivery findings on the above allegations. LPA was greeted by Fernandez, Divina, Administrator (ADM) and explained the purpose of the visit.

During visit, LPA interviewed one (1) resident at 3:30 PM.

During the course of the investigation, LPA interviewed five (5) residents and five (5) staff members. LPA requested the following documents from ADM, Residents roster with contact information, staff rosters with contact information, staff schedule, Incident reports (April and May 2023), and visitors logs (April and May 2023) for 4 of 4 residents.

Continue on Lic9099-C

Substantiated

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-20230512112826

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 and observation conducted, it was alleged that, Staff did not treat resident with dignity or respect and staff did not keep the facility kitchen clean and sanitary. LPA interviewed 5 staff members. On 7/14/2023, S1 told LPA that S2 confessed to S1 about speaking in a rude manner to R1 during dinner service after R1 asked S2 for sugar. S3 stated, after she was done cleaning residents, S3 went to the dinning room and saw S2 raising his hand after dinner service saying, “ if I were to hit you, you would be on the floor”. LPA observed a refrigerator in the kitchen that was not kept clean, and sanitary on 5/16/2023. S2 stated to LPA that the refrigerator is not cleaned as often and is cleaned at least once a week. During today's visit, on 8/8/2023, LPA observed the kitchens refrigerator clean and sanitary.

Based on observation conducted, it was alleged that, Staff did not keep the facility free from cockroaches. LPA observed an infestation of cockroaches all over the kitchen. Cockroaches were around the food warmer, on the side of the sink walls, behind the refrigerator, in the storage room where food is kept, cockroaches crawling on the refrigerator in the storage room, in boxes with cups, and dead cockroaches in the freezer. There were adults, teens, and baby cockroaches that were stuck on sticky traps near the dish washer/sink, food warmer, behind the fridge, and food storage. The Terminix inspector stated, “the infestation was really bad and there needs to be a 1 week clean due to how many there are”. During inspection on 5/16/2023, a Terminix inspector evaluated the facilities kitchen and observed live and dead cockroaches in the kitchen and in the storage room. LPA obtained a copy of a cleaning plan that the Terminix inspector emailed to the Administrator (S1).

Based on interviews conducted, it was alleged that, Staff did not ensure that medications were distributed to residents in a safe manner. LPA confirmed with Rp, S6, and R8 that medication is pre-poured and left out on the medication cart during dining service when residents are walking into the dining room for dinner. Rp stated, the medication cart is assessable to residents in care and residents are able to grab medication that does not belong to them. S6 stated, every afternoon, S4 leaves medication on a tray where it’s assessable for residents to grab. R8 stated, she has seen S4 pre-pour medication and leaves it on the medication cart and walks away from the medication cart where is assessable to other residents in care.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted with ADM, and a copy of this report and appeal rights 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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Control Number 15-AS-20230512112826

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/09/2023 Section Cited CCR 87705(f)(2)	1 2 3 4 5 6 7	87705(f)(2)- Care of Persons with Dementia (f) The following shall be stored inaccessible to persons with dementia. (2) Over-the-counter medication, nutritional supplements or vitamins... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to schedule in-service training with med techs from home health services and to purchase online medication training for all med techs and to submit proof of training and purchase of training to CCL by POC due date.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above by not locking up medication care and leaving medication accessible to residents in care which posed an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 08/09/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a)-Maintenance and Operation: (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. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to assign a staff memeber to clean, and check expiration dates of food to make sure the refrigerator is clean and sanitary at all times and to submit an updated Lic500 to CCL by POC due date.
	8 9 10 11 12 13 14	Based on observation and interview, the licensee did not comply with the section cited above by not keeping the kitchen refridgerator clean and sanity for the safety of residents which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20230512112826

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/15/2023 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1(a)(1) Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall... (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to hold a manditory meeting related to caring for residents with Dementnia and personal rights signed by all staff and to submit a copy of signed in service training to CCL by POC due date.
	8 9 10 11 12 13 14	Based on interview, the licensee did not comply with the section cited above by not speaking to R1 with dignity or respect while in care of staff which posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 08/15/2023 Section Cited CCR 87555(b)(27)	1 2 3 4 5 6 7	87555(b)(27) General Food Service Requirements: (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated that Terminix is still coming to the facility every 2 week and as needed to conduct pest treatment in the kitchen. Administrator agreed to also submit copies of the Terminix treatment for June and July 2023 in what was done and recommondation make by Terminix to CCL by POC due date.
	8 9 10 11 12 13 14	Based on interview, the licensee did not comply with the section cited above by not keeping the kitchen clean from cockroachs and other insects which posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

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