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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200941
Report Date: 11/09/2022
Date Signed: 11/09/2022 03:43:13 PM


Document Has Been Signed on 11/09/2022 03:43 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:DIANE ELDRIDGEFACILITY TYPE:
741
ADDRESS:2671 PLUMMER AVENUETELEPHONE:
(408) 267-4872
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:93CENSUS: 39DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Loren KroekerTIME COMPLETED:
03:46 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 11/09/2022. LPA met with facility Administrator Loren Kroeker (Admin).

LPA toured the facility, including 2 main areas, kitchen, dining room, laundry room, 10 bedrooms, 4 public bathrooms, memory care court yard, activities room. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated.

Facility infectious control plan has already been submitted. No prohibited items noted in resident rooms. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguishers observed to be inspected in February of 2022. Carbon Monoxide detectors observed throughout the facility.

Facility observed to have designated entry point in which temperature is taken and symptoms are screened. 30 day supply of PPE observed. All restrooms stocked with paper towels. Water temperature observed to be between within the acceptable range. Hand washing signs observed in all bathrooms. All bathrooms had garbage cans with foot operated lid. Social distancing signs observed to be posted in all public areas. The facility is currently accepting visitors inside the facility, including residents' bedrooms.

No deficiencies cited during today's visit. This report was reviewed with Administrator Loren Kroeker and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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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