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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200941
Report Date: 10/17/2024
Date Signed: 10/17/2024 12:30:59 PM


Document Has Been Signed on 10/17/2024 12:30 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:JAMES B MORTENSENFACILITY TYPE:
741
ADDRESS:2671 PLUMMER AVENUETELEPHONE:
(408) 267-4872
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:93CENSUS: 38DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator Jame B Mortensen TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Jame B Mortensen. During the visit, ADM stated the facility has 8 residents in memory care and 30 residents in assisted living. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room. LPA toured facility assisted living restrooms and bedrooms, such as, but not limited to rooms: 215, 214, 206, 212, 111, 108, 104, 103, 113, LPA also toured the facility's memory care unit. LPA toured the bedrooms and restrooms, such as, but not limited to rooms: 408, 409, 412, 421,422,424. The staff area of the facility was also inspected. The front and back of the facility was inspected. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 79 degrees F, and hot water temperature was measured at 110 - 112 degrees F in both resident bathrooms.

Fire extinguisher was serviced in February 12, 2024. The facility's sprinkler system was last checked on August 26, 2024. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 2024.

LPA reviewed facility records for 5 staff and 5 residents. LPA reviewed 5 resident medications and centrally stored medication records. LPA conducted interviews with 2 staff and 4 residents.

No deficiencies cited during today's visit. This report was reviewed with Prospective Administrator Chelsea Chanduloy and a copy of the signed report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024
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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