019201495-12-3-2025-15-AS-YFLS-DP6UL2-20251208143959

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201495
Report Date: 12/03/2025
Date Signed: 12/03/2025 03:49:34 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/13/2025 and conducted by Evaluator Patricia Manalo

COMPLAINT CONTROL NUMBER: 15-AS-20250813172258

FACILITY NAME:	LINCOLN VILLA		FACILITY NUMBER:	019201495
ADMINISTRATOR:	DIVINA FERNANDEZ		FACILITY TYPE:	740
ADDRESS:	41040 LINCOLN STREET		TELEPHONE:	(510) 656-4373
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	80	CENSUS: 78	DATE:	12/03/2025
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Divina Fernandez, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident developed pressure injury due to lack of care and supervision.
Staff are not meeting the needs of the resident in care.
Staff do not answer resident's call button in a timely manner.
Staff do not provide adequate food service to resident in care.

INVESTIGATION FINDINGS:

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On 12/03/2025 at 2:05 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to deliver findings on the above allegations. LPA met with Administrator, Divine Fernandez, and explained the purpose of the visit.

During the course of investigation, LPAs interviewed 7 residents, Administrator, and Staff. LPAs obtained copies including but not limited to of the Resident Roster, Staff Schedule, Employee Contact Numbers, Admission Agreement, Identification and Emergency Information, Physician’s Report, Appraisal Needs and Services Plan, Physician’s Fax Reports, After Visit Summaries, Unusual Incident Reports, Agency Visit Report Form, Shower Logs, Shower Shift Cluster Schedule, Call Button Policy, Resident Call Button List, In-House Physician's Notes, Facility Menu, Skin Assessment, Email Correspondence with all responsible parties, and Incontinent Care Log Sheet dated 08/15/2025 to 09/10/2025.

Continue to LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250813172258

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/03/2025

NARRATIVE

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It was alleged that Resident developed pressure injury due to lack of care and supervision.

Interview with the Administrator on 09/11/2025, revealed that R1’s pressure injury has been on and off, and the latest pressure injury was caused by anti-fungal cream. A review of the facility’s Skin Monitoring Daily Skin Check dated 05/23/2025 showed that R1 was developing a pressure ulcer and was noted that on 05/29/2025, R1 had a big tear on left buttocks area. Skin Monitoring Daily Skin Check dated 07/07/2025 showed R1’s pressure injury was staged 1, however, it was noted that it was healing. Skin Monitoring Daily Skin Check dated 08/02/2025, showed that there was a pressure ulcer and staff were applying cream. After Visit Summary dated 08/26/2025 showed that R1 developed a stage 1 pressure sore and was referred to home health to follow up with a wound specialist. A review of the Agency Visit Report Form dated 08/26/2025 noted that R1 does not have an open wound and a review dated 09/08/2025 advised R1 to continue applying anti-fungal cream and encouraged education to R1.

It was alleged that Staff are not meeting the needs of resident in care and Staff do not answer resident’s call button in a timely manner.

On 09/11/2025, LPA P. Manalo and K. Nguyen observed residents’ call button pendant working and staff radio’s being called if a resident needs assistance. According to the facility’s Call Button Policy, staff will respond to immediate safety or medical concerns within 1-2 minutes and non-urgent needs within 5 minutes. Interview with 4 out of 7 residents revealed that there have been no issues with staff assisting with their needs and attending to their calls when needed assistance. Record review of email correspondence between Resident 1 (R1), the facility, and multiple other people showed that R1 would document how long R1 would wait for diaper change or assistance. However, interview with R1 stated that there have been no issues with staff coming for assistance when R1 would call for help. A review of the facility’s Incontinent Care Log Sheet dated 08/20/2025 to 09/11/2025 and Resident Communication Log dated 8/22/2025 to 09/09/2025 showed the date, time, and notes of when R1 would get checked or changed in every shift.

Continue to LIC9099-C...

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250813172258

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/03/2025

NARRATIVE

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Continue from LIC9099-C...

It was alleged that Staff do not provide adequate food service to resident in care.

On 08/14/2025, LPA P. Manalo observed a sufficient supply of perishable and non-perishable food during the visit. LPA observed the fridge, freezer, and pantry filled with various meat products, bread, milk, snacks, etc., Interview with 4 out of 7 residents revealed that the facility provides food for residents 3 times a day and offers snacks. Interview with Resident 7 (R7) disclosed that if there is a food item that they don’t eat, facility staff will accommodate to the type of food they want.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025

LIC9099 (FAS) - (06/04)

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