435200941-9-25-2023-26-AS-MMOR-CVZVCH-20230925161910

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200941
Report Date: 09/22/2023
Date Signed: 09/25/2023 04:20:14 PM

Document Has Been Signed on 09/25/2023 04:20 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 CENTER		FACILITY NUMBER:	435200941
ADMINISTRATOR:	DIANE ELDRIDGE		FACILITY TYPE:	741
ADDRESS:	2671 PLUMMER AVENUE		TELEPHONE:	(408) 267-4872
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	93	CENSUS: 43	DATE:	09/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Administrator Diane Eldridge		TIME COMPLETED:	04:45 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	On 09/22/2023, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced required annual inspection at the facility today. LPA met with Diane Eldridge, Administrator. LPA explained the purpose of the visit. LPA toured the facility inside and out. The tour included the following; the assisted living, dementia program, the activity areas in both buildings and dining/kitchen areas. LPA also toured the following memory care resident bedrooms which included, but not limited to rooms; 408, 405, & 406. LPA also toured the following assisted living residents bedrooms, which included, but not limited to the following rooms; 102, 109, 111, 204. LPA observed resident bedrooms and bathrooms to be clean, organized and fully furnished. The main kitchen was inspected, menus with special diets was observed. LPA observed staff and residents engaged in a Hawaii themed event in the dinning room. The perishable and nonperishable food is observed. All interior and exterior passageways were observed to be free of obstruction. Fire extinguishers observed in the facilities was tagged with a last inspection record date of 02/07/2023. The Room temperature in both buildings was set at a comfortable 75 degrees F. The facility is equipped with all required equipment including exit alarms, signal alerts, grab bars, non-skid mats locked storage for toxic materials and medication was observed. Facility is equipped with First Aid Kit. The facility was observed to be clean, sanitary, and in good repair. The facility's last fire drill conducted was on July 12, 2023. The hot water temperature in both buildings were measured. The memory care building water temperature ranged from 106 and 108 degrees Fahrenheit (Memory care bedrooms 405 & 108). The assisted living building water temperature ranged from 109 degrees Fahrenheit and 110 degrees Fahrenheit. (Assisted living bedrooms 103 & 204). ADM tested the delayed egress alarms in the memory care building and staff responded in less than 15 seconds. Page 1 out of 2

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (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)

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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: 09/22/2023

NARRATIVE

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3 Residents records were reviewed. A memory care resident, R1's physicians report is dated 07/06/2022. R1's appraisals needs and services plan is dated 10/18/2022. The needs and services plan for R1 has not been updated to reflect the changes in care implemented. ADM stated R1 now on 15 minute checks and added to the facility's elopement risk list. LPA also reviewed 3 staff files. Medication records were reviewed against the centrally stored log. LPA also interviewed 3 staff and 3 residents.

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.

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SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (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

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 09/25/2023 04:20 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the ADM did not comply with the section cited above. R1's physicians report is dated 07/06/2022. ADM stated his/her next doctors appointment is next month. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	ADM stated she will send a plan of action on how the facility will make sure dementia residents have their annual medical assessment. ADM will send plan to LPA by POC date.

Type B

Section Cited

CCR

87705(c)(6)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the ADM did not comply with the section cited above. ADM stated R1 recently had a change in care, 15 minute checks and being added to elopement risk list. This change in care was not reflected on R1's needs and services plan, dated 10/18/2022. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	ADM stated she will send LPA updated needs and services plan to LPA by POC date.

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 Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (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)

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