<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200941
Report Date: 09/22/2023
Date Signed: 09/25/2023 04:21:39 PM


Document Has Been Signed on 09/25/2023 04:21 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: 43DATE:
09/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Diane EldridgeTIME COMPLETED:
04:30 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
Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit in regards to an incident report the department received on 8/24/2023. LPA met with Administrator (ADM) Diane Eldridge and explained the purpose of the visit.

On 08/24/2023, the department received an incident report stating the resident R1 had eloped from the facility. The incident report stated the following; the elopement occurred on 08/23/2023. The search initiated immediately. Staff searched all the rooms, other building, and the surrounding area but could not find R1. Facility staff notified the police. A citizen had found the resident and notified the police. The police then notified the facility and a staff member picked up R1. The form also states an urgent work order was placed that morning to fix the alarm so it transmits to the radios the aids carry. The form also states the resident has not wandered before and is now on 15 minute checks and has been added to the elopement risk list.

Based on a review of R1's physicians report, R1 has dementia and cannot leave the facility unassisted.

Based on an interview with staff, S1. R1 had left the facility around 7:30pm. S1 stated the staff check the surrounding shopping centers but were unable to locate R1, so they contacted the police.

Based on record review, on 08/23/2023, at approximately 8:35pm, R1 was found by a citizen.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
This report was reviewed with Administrator Diane Elbridge and a copy of the report was provided. Appeal Rights was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
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 2


Document Has Been Signed on 09/25/2023 04:21 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2023
Section Cited
CCR
87705(k)(4)

1
2
3
4
5
6
7
(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices ... (4)Without violating Section 87468, Personal Rights, facility staff shall attempt to redirect a resident who attempts to leave the facility.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
ADM stated she will send plan of action on how the facility will keep memory care residents safe and prevent elopments.
8
9
10
11
12
13
14
Based on interview and record review, the ADM did not ensure facility staff attempted to redirect resident (R1) from leaving the facility unassisted which poses an immediate Health and Safety risk to persons in care.
8
9
10
11
12
13
14
Type B
09/29/2023
Section Cited
CCR87303(a)

1
2
3
4
5
6
7
87303 Maintenance and Operation (a) The facility shall be... in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents...
This requirement was not met as evidenced by;
1
2
3
4
5
6
7
ADM stated she will send plan of action to make sure alarm systems in the memory care unit remain in good repair at all times.
8
9
10
11
12
13
14
Based on record review and interview, the ADM did not ensure the delay egress alarm was functioning and in good repair at all times. This poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2