435200941-10-16-2025-26-AS-RMAO-DN6PCG-20251106101152

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200941
Report Date: 10/16/2025
Date Signed: 10/16/2025 12:45:21 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/01/2025 and conducted by Evaluator Manuel Monter

COMPLAINT CONTROL NUMBER: 26-AS-20251001111956

FACILITY NAME:	LINCOLN GLEN ASSISTED LIVING CENTER		FACILITY NUMBER:	435200941
ADMINISTRATOR:	JAMES B MORTENSEN		FACILITY TYPE:	741
ADDRESS:	2671 PLUMMER AVENUE		TELEPHONE:	(408) 267-4872
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	93	CENSUS: 40	DATE:	10/16/2025
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Acting Director of Health Services Scott Self		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Resident sustained injuries due to lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Acting Director of Health Services Scott Self.

On October 1, 2025 the Department received a complaint alleging resident sustained injuries due to lack of supervision. It has been alleged that staff’s neglect/lack of supervision resulted in R1 sustaining injuries on September 28, 2025.

On October 6, 2025, the Department received an incident report regarding R1, dated September 28, 2025. The incident report stated, on September 28, 2025, around 4:45pm, R1 was found lying face down on the floor, next to his/her recliner. R1 was noted with bleeding to his/her left temple and top of his/her nose. 911 was called.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 26-AS-20251001111956

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LINCOLN GLEN ASSISTED LIVING CENTER	FACILITY NUMBER: 435200941
	VISIT DATE: 10/16/2025

NARRATIVE

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On October 3, 2025, LPA Monter conducted the initial complaint investigation visit. LPA attempted to interview resident R1. R1 stated he/she declined to be interviewed.

LPA interviewed staff S1-S7. 7 Out of 7 staff interviewed stated R1 needs assistance with transfers from bed/ recliner /wheel chair. 7 Out of 7 staff interviewed stated R1 is a fall risk. 5 Out of 7 staff (S2- S4, S6, S7) interviewed stated they were not working at the facility on September 29, 2025 during the PM shift, when R1 fell.

S1 stated on September 28, 2025, around 4pm, R1 requested to be taken to his/her room to sit on his/her recliner. S1 stated he/she assisted R1 to his/her room. S1 stated 15 minutes later, he/she went to assist another resident, who’s room was in the same direction. S1 stated as he/she was passing by R1’s room, he/she did a visual check on R1, who was still seated on his/her recliner. S1 stated when a staff walks by R1’s room, R1’s recliner is within the line of sight of the hallway and stated on September 28, 2025, R1’s room door was open. S1 stated after he/she had finished helping another resident, he/she heard a thud sound. S1 stated he/she entered R1’s bedroom around 4:30pm and saw R1 sitting next to the recliner. S1 stated R1 was assessed by the hospice nurse who advised R1 going to the hospital.

S5 stated on September 29, 2025, he/she saw R1 last around 4pm, in the activity area. S5 stated R1 was taken to his/her room by staff S1. S5 stated at around 4:30-4:40pm, was when R1 was found to have fallen by staff S1. S5 stated he/she was in the activity area of the memory care unit when this happened. S5 stated he/she didn’t hear any yells, screams or calls for help.

On October 7 and 9, 2025, LPA Monter interviewed staff S8 and S9. S8 stated he/she wasn’t working on September 29, 2025, when R1 had fallen.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20251001111956

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LINCOLN GLEN ASSISTED LIVING CENTER	FACILITY NUMBER: 435200941
	VISIT DATE: 10/16/2025

NARRATIVE

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S9 stated when he/she clocked in on September 29, 2025 around 2:00pm, he/she saw R1 seated in the living room. S9 stated while she was working in the med room, some time has passed. S9 stated a resident R2 had called for assistance and went to assist this resident. S9 stated as he/she was headed to R2’s Bedroom, he/she saw that R1 was no longer in the living room. S9 stated R1’s room is in the walkway and as he/she passed R1’s room, he/she saw from the hallway that R1 was seated on his/her recliner. S9 stated after assisting R2, he/she returned to the med room and saw R1, still seated on his/her recliner. S9 stated he/she didn’t check the time and doesn’t know exactly what time he/she saw R1 last. S9 stated when he/she returned to the medroom, he/she was preparing the 5pm medications. S9 stated then one of the new staff informed him/her that R1 had fallen. S9 stated he/she then went to check R1 immediately. S9 stated he/she observed R1 has sustained an injury due to the fall.

On October 16, 2025, LPA Monter interviewed Staff Acting Director of Health Services Scott Self, referred to as HS. HS stated R1 is currently a 1 person assist for all ADLs. HS stated R1 can get up on his/her own but has weakness. HS the facility is doing 2 hour checks for R1. HS stated if R1 tries to get up, staff will assist R1 in going to where he/she wants to go. HS stated R1 has a pendant if he/she needs help, but will spend most of his/her day in the living room. HS R1 is considered a fall risk.

The Department reviewed R1's Physician's Report dated June 3, 2025. Based on a review of R1’s Physician's Report, R1 has a neurocognitive disorder. R1 requires assistance with repositioning and transferring.

The Department reviewed R1's Needs and Services Plan, dated August 30, 2024. R1’s Needs and Services Plan states that R1 needs to be escorted back to room after activity as needed. Remind resident to ask for assistance when the need for toileting comes. Assist with lowering and raising of clothing.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025

LIC9099 (FAS) - (06/04)

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