019201025-4-12-2023-15-AS-LFII-CQU2MA-20230412173048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019201025
Report Date: 04/12/2023
Date Signed: 04/12/2023 05:31:01 PM

Document Has Been Signed on 04/12/2023 05:31 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 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: 57	DATE:	04/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Med Tech, Marissa Tangonan		TIME COMPLETED:	05:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 4/12/2023 starting at 10:00 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Med Tech, Marissa Tangonan and explained the purpose of the visit. The facility’s fire clearance was approved for all seventy-six (76) non-ambulatory residents, which 76 may be bedridden and approved for ten (10) hospice waivers. LPA verified that administrators certificate is current. At 10:43 AM, Steve Comtiag, LVN met with LPA and assisted LPA with todays visit. Starting at 10:50 AM, LPA toured facility with LVN including but not limited to four six (46) bedrooms, forty-six (46) bathrooms, kitchen, common area, dinning area and courtyard. The facility consists of 46 total bedrooms which 9 bedrooms are private, and 37 bedrooms are shared. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents'. The hot water temperature in residents’ private bathroom was measured at 114.5 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day of perishable foods. Sharps were locked and inaccessible to residents'. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed last serviced on 8/23/2022. First aid kit was observed to be complete. Continue on Lic809-C (Page 1 of 2)

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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 3

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: 04/12/2023

NARRATIVE

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Continued from Lic809 (Page 2 of 2)

Starting At 11:36 AM, LPA reviewed 5 of 5 staff records. At 1:26 PM, LPA reviewed 5 of 5 residents' records. At 3:10 PM, LPA reviewed a sample of 5 of 5 residents' medications.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

At 12:40 PM, LPA observed during record review that S4, and S5 do not have First aid and CPR training on file.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 4/19/2023:

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 Pages)
· Liability Insurance

Exit interview conducted with LVN, and a copy of this report provided along with appeal rights.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 04/12/2023 05:31 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: 04/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)(3)

1569.618(c)(3)- Administration and management of residential care facilities; substituted qualifications; employee scheduling: (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by allowing S4, and S5 to work with residents without proper First aid and CPR training which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator agrees to obtain First aid and CPR training for S4, and S5 and to submit a copy of First aid and CPR certificate to CCLD.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3