397005690-9-19-2023-27-AS-MJEN-CVTQWX-20230919123241

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397005690
Report Date: 09/19/2023
Date Signed: 09/19/2023 12:32:52 PM

Document Has Been Signed on 09/19/2023 12:32 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	LINCOLN MANOR		FACILITY NUMBER:	397005690
ADMINISTRATOR:	MANZANO, MARY ANN		FACILITY TYPE:	740
ADDRESS:	934 KATHERINE WAY		TELEPHONE:	(209) 513-8913
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY:	6	CENSUS: 5	DATE:	09/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Dolly Aparici		TIME COMPLETED:	12:45 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 9/19/23 at approximately 10:30 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with care provider Dolly Aparici and explained the purpose of today's visit. The facility is licensed for 6 non-ambulatory clients, 1 of which may be bedridden and has a hospice waiver for 3. The facility offers dementia care. The Administrator has a current Administrator's certificate good through October 2024. LPA Jensen toured the grounds and observed the grounds to be maintained and all paths were clear of obstruction. There are no bodies of water on the property. The facility currently has 5 clients, 2 of which are on hospice and 1 which bedridden. The facility was determined to be operating within the scope of their license. LPA Jensen the clients engaged in enrichment activities including singing and art work. The facility was observed to be sanitary and free of odor. There was adequate furniture and lighting observed throughout. The facility maintains adequate linen and hygiene supplies. The water temperature in the ensuite of the master bedroom was measured at 111 degrees Fahrenheit and is compliance. The bathrooms have grab bars at the toilet and shower and non-slip mats. The thermostat was set at a comfortable temperature for clients. The facility maintains in excess of a 2 day supply of perishable food and a 7 day supply of non-perishable food. There is also a sufficient supply of emergency food on site. Knives, toxins and medications are kept locked and inaccessible to residents in care. LPA Jensen reviewed the emergency disaster plan and determined it to be in compliance. The facility conducts regular fire drills that are logged. The fire extinguisher was last serviced in July of 2023 and is in compliance. Continued on LIC 809C...

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LINCOLN MANOR	FACILITY NUMBER: 397005690
	VISIT DATE: 09/19/2023

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
26
27
28
29
30
31
32

Continued from LIC 809C...

The smoke detector and carbon monoxide detector were determined to be in good working order. The first aid kit was observed to be complete.

LPA Jensen reviewed 5 of 5 resident files and determined them to be complete. LPA Jensen reviewed 2 of staff files and determined them to be complete. The facility maintains current liability insurance that meets that minimum required thresholds.

The inspection tool was utilized during the course of this inspection. The facility was found to be in substantial compliance and no citations are being issued.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4