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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201495
Report Date: 03/20/2025
Date Signed: 03/20/2025 02:06:16 PM

Document Has Been Signed on 03/20/2025 02:06 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LINCOLN VILLAFACILITY NUMBER:
019201495
ADMINISTRATOR/
DIRECTOR:		WU, LULINFACILITY TYPE:
740
ADDRESS:41040 LINCOLN STREETTELEPHONE:
(510) 656-4373
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 80CENSUS: 68DATE:
03/20/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Wendy Wong and Olive Manalasta TIME VISIT/
INSPECTION COMPLETED:
01:13 PM
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On 03/20/2025 at 9:30 AM, Licensing Program Analysts (LPAs) P. Manalo and K.Nguyen arrived announced to conduct pre licensing inspection. LPAs met with Licensee/ Applicant, Wendy Wong, Olive Manalasta, and Administrator, Divina Fernadez, and explained the purpose of the visit. This is pre-license for a change of ownership.

LPAs toured facility with Administrator and Licensees/ Applicants including but not limited to a sample of 4 residents' bedrooms, 3 bathrooms, kitchen, dining hall, resident lounge, and courtyard. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. The hot water temperature in a sample of residents’ shared bathroom were measured at 110.3 and 109.8 degrees Fahrenheit. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguishers were last serviced on 08/09/2024. The facility has a working telephone that was verified during the visit.

Prior to licensure, the following shall be corrected and faxed to CCL by 04/10/2025:
  • At 10:50 AM, LPA observed the Med cart unlocked, and medications were found in Room #3, Room #15, and Room #31.
  • At 11:00 AM, LPAs observed that the freezer did not have a thermostat inside.
  • At 11:05 AM, LPAs observed food not properly stored in containers.
  • At 11:15 AM, LPAs observed that there is not enough emergency food.
  • At 11:26 AM, LPAs observed window screens with holes and clutter outside in the courtyard that needs to be removed.


Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LINCOLN VILLA
FACILITY NUMBER: 019201495
VISIT DATE: 03/20/2025
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Continue from LIC809...
  • At 11:45 AM, LPAs observed that staff did not have emergency flashlights available.
  • At 12:00 PM, LPAs observed Lysol Cleaning wipes in Room #26 and shower grease spray, deep cleaning spray in Room #15.
  • At 12:15 PM, LPAs observed the residents' records were found to be incomplete.

This facility is not ready to be licensed. The facility will notify LPA after all the corrections have been corrected.

Exit interview was conducted and a copy of this report was provided to Licensee/applicant.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
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