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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200941
Report Date: 04/03/2025
Date Signed: 04/03/2025 10:55:36 AM

Document Has Been Signed on 04/03/2025 10:55 AM - 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: 49DATE:
04/03/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Assisted Living Administrator Chelsea ChanduloyTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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Licensing Program Analysts (LPA) Manuel Monter arrived unannounced to conduct a case management visit to follow up on a medication error. LPAs met with Assisted Living Administrator (AL) Chelsea Chanduloy and stated the purpose of the visit.

On February 24, 2025 the Department received an Incident Report for a medication error of Resident R1 that occurred on February 22, 2025. The incident report states, resident R1 was accidentally administered the wrong dose of medicine. Instead of Medication M1's 25mg tablet, a medication M2 50 mg tablet was given.

On April 3, 2025, LPA interviewed AL. AL stated the medication error only occurred once. AL stated what occurred that day, resident R1 told staff that he/administered two larger tablets instead of two smaller tablets that afternoon. AL stated R1 was administered the wrong dosage. AL stated the very same day R1's doctor/ family was notified. AL stated staff was told observe the resident and check blood pressure. AL stated R1 did not have a change to his her status the same day and the following day. AL stated R1 continued on his/her regular routine, with no issues noted.

AL stated staff S1 was given training. AL stated the health services coordinator went over R1's medications with staff S1 to ensure R1's medications are being administered as prescribed. LPA received copies of R1's training's.


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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2025
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: 04/03/2025
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Based on a review of R1's physician's report dated, August 7, 2019, R1 cannot administer his/her own medications.

A deficiency is being issued during today's visit per California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted with Assisted Living Administrator Chelsea Chanduloy and a copy of this report was provided. Appeal rights were also provided.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/03/2025 10:55 AM - It Cannot Be Edited


Created By: Manuel Monter On 04/03/2025 at 10:38 AM
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: 04/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2025
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs

This requirement was not met as evidenced by
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Administrator stated the facility conducted an in-service for staff S1 on medication training on 2/22/2025.

ADM provided documentation of in-service training conducted on 2/22/2025.
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Based on investigation, on 2/22/2025, Staff S1 administered 1 incorrect dose of medication M1 to R1 which poses an immediate health, safety and personal rights risk to persons in care.
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ADM stated she will also be conducting another hands on training on 4/4/25, and will send LPA documentation showing the training has been completed.

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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: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


LIC809 (FAS) - (06/04)
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