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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201025
Report Date: 03/24/2024
Date Signed: 03/24/2024 06:50:43 PM


Document Has Been Signed on 03/24/2024 06:50 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: 54DATE:
03/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Divina Fernandez, AdministratorTIME COMPLETED:
07:10 PM
NARRATIVE
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On 3/24/2024 at 9:55AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with LVN, Leah Agron and explained the purpose of the visit. Administrator, Divina Fernandez arrived an hour and a half later. The facility’s fire clearance was approved for 76 non-ambulatory residents of which 76 may be bedridden and 10 residents may be under hospice care.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, common areas, and outdoor area. Centrally stored medications were locked in medication carts and medication room. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguisher was observed to be full and last serviced on 8/8/2023. One week supply of nonperishable and 2-day supply of perishable foods were available. Facility purchase food once a week. Freezer temperature was measured at -20 degrees F and the refrigerator was measured at 40 degrees F. Hot water temperature was measured at 115.7 degrees F in a resident's bathroom sink. Grab bars for each shower and toilet were installed. Non-skid mats were observed. There were adequate lights in each room. Indoor and outdoor passages were free of obstruction.

LPA reviewed 5 resident records and 5 staff records starting at 10:50AM. LPA conducted interviews with 4 residents and 4 staff during inspection. LPA also reviewed a sample of resident's medications and MAR (Medication Administration Record).

At 11:30AM, LPA observed R1 and R2 does not have current medical assessment on file. R1, R2, R3, R4, and R5 does not have current needs and service plans on file.

At 11:45AM, LPA observed R3 does not have TB test results on file.
(Continue on LIC809C...)
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2024
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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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
VISIT DATE: 03/24/2024
NARRATIVE
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At 11:55AM, LPA observed S4 is not fingerprint cleared. LPA checked on Guardian website to verified that S4 does not have criminal record clearance. S4 left the facility and will not return to the facility until fingerprint cleared. Civil penalty of $500 is being assessed.

At 12:10PM, LPA observed S3 and S4 does not have current first aid training on file.

At 12:20PM, LPA observed S3 and S4 does not have health screening and TB test results on file.

At 12:40PM, LPA observed S5 does not have current annual training on file.

At 4:00PM, LPA was informed by administrator that facility has conducted disaster drills and did not document the drills. LPA was not able to verified if disaster drills were completed.

At 5:30PM, LPA observed R3 had order for Finasteride 5mg. However, facility does not have the prescription available at the facility. R3 does not have a D/C (discontinue) order for this medications.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted with Divina Fernandez. A copy of this report, civil penalty, and appeal rights were provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2024 06:50 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: 03/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above by not having S4 fingerprint cleared prior to working at the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Administrator asked S4 to leave the facility during inspection. Administrator will follow up with Guardian regarding S4's fingerprint clearance and submit communication to CCLD by POC date.
Civil penalty of $500 is being assessed.
Type A
Section Cited
CCR
87465(c)(2)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having R3's medication available which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/25/2024
Plan of Correction
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Administrator has agreed to obtain R3's medication or obtain a discontinue order from the doctor. Administrator will submit communication or picture of medication to CCLD by POC date.
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: 03/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 03/24/2024 06:50 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: 03/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current medical assessment for two residents and not having current reappraisals for five residents which poses a potential health and safety risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Administrator has agreed to obtain current medical assessment for R1 and R2 and obtain current reappraisals for R1, R2, R3, R4, and R5. Administrator will submit the documents to CCLD by POC date.
Type B
Section Cited
CCR
87458(b)(1)
(b) The medical assessment shall include, but not be limited to:
(1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having TB test for R3 which poses a potential health and safety risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Administrator has agreed to obtain R3's TB test results and submit a copy to CCLD by POC date.
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: 03/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 03/24/2024 06:50 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: 03/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current First Aid training for two staff which poses a potential health and safety risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Administrator has agreed to obtain current first aid training for S3 and S4 and submit copies of completion to CCLD by POC date.
Type B
Section Cited
CCR
87411(f)
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties...
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having health screening and TB test for two staff which poses a potential health and safety risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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Administrator has agreed to obtain health screening and TB test results for S3 and S4 and submit copies to CCLD by POC date.
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: 03/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 03/24/2024 06:50 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: 03/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on record review, the licensee did not comply with the section cited above by not having current annual training for S5 which poses a potential health and safety risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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3
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Administrator has agreed to obtain and submit current annual training for S5 to CCLD by POC date.
Type B
Section Cited
HSC
1569.695(c)
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above by not having disaster drill log which poses a potential health and safety risk to persons in care.
POC Due Date: 04/19/2024
Plan of Correction
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2
3
4
Administrator has agreed to conduct disaster drill and submit disaster drill log to CCLD by POC date.
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: 03/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6