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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200941
Report Date: 04/16/2025
Date Signed: 04/16/2025 12:39:47 PM

Document Has Been Signed on 04/16/2025 12:39 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LINCOLN GLEN ASSISTED LIVING CENTERFACILITY NUMBER:
435200941
ADMINISTRATOR/
DIRECTOR:		JAMES B MORTENSENFACILITY TYPE:
741
ADDRESS:2671 PLUMMER AVENUETELEPHONE:
(408) 267-4872
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 93CENSUS: 43DATE:
04/16/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Memory Care Director (MCD) Evelyn LaxTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst Manuel Monter conducted an unannounced case management visit-incident regarding an incident report, which stated a resident had eloped from the facility. LPA was also conducting a POC visit LPA met with Memory Care Director (MCD) Evelyn Lax. LPAs explained the purpose of the visit.

On April 7, 2025, the Department received an incident report (LIC624) regarding a resident (referred as R1) who eloped from the facility. According to the report, on April 5, 2025, around 4pm, resident R1 got out through the side gate. R1 was found by members of St. Christopher’s Church. Members of St. Christopher’s Church called R1’s family member with his/her phone. R1 was brought back to the facility by his/her family who met R1 there.

On April 7 and April 10, 2025, LPA Monter interviewed ADM James Mortensen and Staff S1. ADM and S1 stated R1 doesn't have propensity for wandering. ADM and S1 stated the building R1 was at, has delayed egress. ADM stated the doors make an audible sound and a sound stating the door had been activated, via the walkie talkie. ADM stated R1 exited thru the delayed egress. ADM stated the staff went to investigate. ADM stated staff stated the door alarm was not heard by the staff. ADM stated the staff went and deactivated the door. ADM and S1 stated the staff did not follow the protocol and do a head count after the door alarm activated. ADM and S1 stated the elopement occurred around 4pm. ADM and S1 stated maybe by 5pm R1 was found. ADM stated and S1 stated R1 was found at St. Christopher's Church. (Based on a google maps review of the location R1 was found, R1 was 0.9 miles away from the facility). ADM stated the churchgoers contacted the R1’s family member. ADM and S1 R1’s family member brought R1 back to the facility.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
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: 04/16/2025
NARRATIVE
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On April 10, 2025, LPA Monter interview Witness W1. W1 stated the day of the elopement she/he received a phone call from his/her family member, at 5:24pm. W1 stated his/her family member had called him/her to tell her that R1 managed to leave the facility and was found at the St. Christopher's church. W1 stated he/she immediately called the facility to inform them. W1 called R1 who had his/her cell phone and confirmed he/she was at the church. W1 stated he/she went to the church to pick up R1. W1 stated R1 was standing with a churchgoer, who stated R1 attended the entire mass. W1 stated he/she brought R1 back to the facility.

Based on a review of R1’s Physician’s Report, dated February 21, 2025, R1 has a neurocognitive disorder. The physician’s report also states R1 has wandering behavior.

The Department reviewed R1’ s Needs & Services Plan (ANS) dated March 5, 2025. The ANS states that one of R1’s Needs/Problem is including wandering. Furthermore, the ANS states, R1 will not leave the facility without proper supervision & staff will supervise resident and be aware of whereabouts at all times.

As a result, the department issued an immediate civil penalty of $500 for absence of supervision, which resulted in R1 eloping from the facility. An additional Civil Penalty of $250 is being cited for a repeat violation, for the following code section: 87411 Personnel Requirements - General (a), which was cited during a case management visit on April 3, 2025.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
This report was reviewed with Memory Care Director Evelyn Lax and a copy of the report was provided. Appeal Rights was provided.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/16/2025 12:39 PM - It Cannot Be Edited


Created By: Manuel Monter On 04/16/2025 at 11:31 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LINCOLN GLEN ASSISTED LIVING CENTER
FACILITY NUMBER: 435200941

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2025
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs

This requirement was not met as evidenced by
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MCD stated the facility conducted an in-service for staff regarding: Elopment policies and protocols.

MCD provided LPA with copy of training conducted on April 10, 2025.
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Based on investigation, on 04/05/25, R1 had exited the facility via the delayed egress. ADM stated staff went & deactivated the door, but did not do a head count after the alarm activated.This poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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MCD provided LPA with documenation during Visit.
Type A
04/17/2025
Section Cited
CCR87468.1(a)(2)

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87468.1 Personal Rights: (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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MCD stated they have upgraded the alarm system. MCD stated they have also added another alarm system, that will page the radio, which informs staff which door had been activiated. MCD stated they have also change the faciltiy entry procedure and added additonal elopement risk questions to apprisal.
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Based on investigation, on 04/05/2025, R1 with a neurocognitive disorder left the memory care unit unassisted and was found 0.9 miles away from the facility, unsupervised. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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MCD stated they have also implemented weekly elopement training, wherin she will activate the delayed egress and note response time. MCD stated the facility also implemented a wander guard as well.
MCD provided LPA with documenation during Visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025


LIC809 (FAS) - (06/04)
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