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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201495
Report Date: 04/03/2026
Date Signed: 04/03/2026 03:58:14 PM

Document Has Been Signed on 04/03/2026 03:58 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:		DIVINA FERNANDEZFACILITY TYPE:
740
ADDRESS:41040 LINCOLN STREETTELEPHONE:
(510) 656-4373
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 80CENSUS: 76DATE:
04/03/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Divina Fernandez, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 04/03/2026 at 12:15 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported AWOL incidents that occurred on 03/28/2026. LPA met with Administrator (ADM), Divina Fernandez, and explained the purpose of the visit.

On 04/01/2026, LPA P. Manalo received an incident report that indicated that on 03/28/2026, R1 and R2 AWOL’D from the facility at different times. R1 AWOL'D from the facility at approximately 11:00 AM and was found down the street using the GPS monitoring system. Incident report also indicated that during the time R1 AWOL'D, the alarm system was not working. Another incident dated 03/28/2026 revealed that R2 AWOL'D from the facility at approximately 2:15 PM during shift change and was also found outside near the street with the use of the GPS monitoring system.

During the visit, LPA and ADM observed R3 test if the front door would set off while the resident attempted to leave. The front door alarm did not set off, and ADM stated that the door will not alarm if the resident's waunder guard bracelet is covered by the resident's clothing. However, when R1 tested the front door to see if it would alarm, the sound still did not set off and R1's waunder bracelet was observed to not be covered with anything. It was also observed that the facility installed a facial recognition. Interview with ADM revealed that the facial recognition recognizes the residents' who are known wanderers and will notify the facility via telephone if a resident attempts to leave through the front or side doors. It was observed that the facial recognition was working and it would call the facility's phone if a resident attempted to go out.

Continue to LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2026
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LINCOLN VILLA
FACILITY NUMBER: 019201495
VISIT DATE: 04/03/2026
NARRATIVE
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Continued from LIC809...

LPA reviewed R1 and R2's physician report indicated that they are both not able to leave the facility unassisted. A review of the Medroom Communication Log indicated that for both residents it was noted that the resident was nowhere to be found and the facility staff were able to locate the residents with the GPS monitoring system. Interview with ADM and S1 confirmed that during the time of the residents' AWOL'D, the alarm system was not working. S1 also stated that the system was fixed the next day, but based on the observations done today, the alarm sound was still not working at the front door.

The following deficiencies was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalty.

Exit interview conducted. Appeal Rights, LIC421FC, and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/03/2026 03:58 PM - It Cannot Be Edited


Created By: Patricia Manalo On 04/03/2026 at 03:16 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LINCOLN VILLA
FACILITY NUMBER: 019201495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2026
Section Cited
CCR
87303(a)

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87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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By POC date, the Administrator (ADM) agrees to contact the alarm system to see what the issue is with the alarm system not sounding. Then, based off that information, Administrator will notify LPA of what their plan is for the alarm system.
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Based on interview, the licensee did not comply with the section cited above when the alarm system for the facility door was in disrepair which posed a potential safety risk to persons in care.
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Type B
04/10/2026
Section Cited
CCR87468.2(a)(4)

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87468.2(a)(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

This requirement is not met as evidenced by:
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By POC date, the Administrator will request for R1 to have a 1:1 and do a two hour check in for R2. In addition, Administrator will create an activity schedule for the next two weeks and send proof to CCLD.
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Based on interview and record review, the licensee did not comply with the section cited above when R1 and R2 AWOL'D from the facility on the same day which posed a potential safety risk to persons in care.
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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.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2026


LIC809 (FAS) - (06/04)
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