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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200941
Report Date: 10/16/2025
Date Signed: 10/16/2025 12:57:15 PM

Document Has Been Signed on 10/16/2025 12:57 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: 40DATE:
10/16/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Acting Director of Health Services Scott SelfTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to deliver the results of a complaint investigation 26-AS-20251001111956. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA is also following up on an incident report received on 10/16/2025. LPA met with Acting Director of Health Services Scott Self

Wile investigating the complaint 26-AS-20251001111956, regarding R1, LPA noted issues in resident R1's Care plan.

The Department reviewed resident R1’s Progress notes. Progress note dated August 7, 2025 states around 2:30pm, R1 had an unwitnessed fall in his/her bathroom. R1 claimed he/she slipped when trying to use his/her toilet. R1 was able to move all extremities without pain, no complaints of pain, no visible bruises.

Progress note dated September 27, 2025, R1 had an unwitnessed fall around 1:40pm. Staff brought resident to his/her room to rest on recliner, then 10 minutes later, a thud was heard. Staff checked on R1 and found him/her next to recliner. Resident was assisted, and no injuries noted.

On October 6, 2025, the Department received an incident report regarding R1, dated September 27, 2025. The incident report stated, on September 27, 2025, around 1:40pm, R1 was found sitting on the floor next to his/her chair. R1 stated he/she lost his/her balance and fell. Hospice noticed a small lump on the right side of head. R1 denies pain. R1’s POA was notified and stated he/she didn’t want R1 to be sent to the hospital.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST 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.

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: 10/16/2025
NARRATIVE
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Based on a review of R1’s Physician's Report, dated June 3, 2025, 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. The Care plan states 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 a review, this care plan was not updated to address R1's requiring assistance with transferring and does not detail a plan to address R1's recent falls prior to September 28, 2025.

Incident Report October 11, 2025

On October 16, 2025, the Department received an incident report regarding resident R2. The incident report stated, on October 11, 2025, at 9:00pm, the family of R2 brought a new prescription, medication M1. Family did not inform medtech they had already given dose to resident when they arrived. Med tech started the medication and resident was given a double dose within an hour.

On October 16, 2025, LPA interviewed Acting Director of Health Services Scott Self, (HS). HS stated the medtech did not follow procedures when receiving a new medication. HS stated the medtech did follow facility procedures, and did not do a physical count of the medication that just arrived, before administering the medication. HS stated they are doing an in-service today regarding medication administration guidelines and receiving medication administration.

Based on a review of R2's physician's report, dated, March 13, 2025, R2 cannot store or administer his/her own medications.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Acting Director of Health Services Scott Self and a copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST 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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2025 12:57 PM - It Cannot Be Edited


Created By: Manuel Monter On 10/16/2025 at 12:11 PM
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: 10/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2025
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care(a) (4) The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by;
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HS stated they are doing an in-service today regarding medication administration guidelines and receiving medication administration. HS stated he will send LPA documenation this training has taken place.
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Based on investigation, the facility administered an additional dose of M1. Medtech did follow facility procedures, and didn't do a physical count of the medication that just arrived. This poses a potential health, safety and personal rights risks to persons in care.
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HS stated he will send a copy to LPA by POC due date October 23, 2025
Type B
10/23/2025
Section Cited
CCR87463(a)

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87463 Reappraisals (a) The pre-admission appraisal,... shall be updated in writing as frequently as necessary... to note significant changes in condition... to keep the appraisal accurate...
This requirement was not met as evidenced by;
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HS stated on September 28, 2025, R1's care plan was updated to address R1's falls. HS stated he will send a letter of understanding regarding the regulation.
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Based on record review, R1's Needs and Services plan was not updated to address R1's falls that occured on 8/7/25 and 9/27/25, and how the facility will address this need. This poses a potential health, safety and personal rights risks to persons in care.
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HS stated he will send a copy to LPA by POC due date October 23, 2025
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: 10/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2025


LIC809 (FAS) - (06/04)
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