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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201495
Report Date: 04/30/2026
Date Signed: 04/30/2026 04:18:32 PM

Substantiated


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
04/24/2026 and conducted by Evaluator Patricia Manalo
COMPLAINT CONTROL NUMBER: 15-AS-20260424121354
FACILITY NAME:LINCOLN VILLAFACILITY NUMBER:
019201495
ADMINISTRATOR:DIVINA FERNANDEZFACILITY TYPE:
740
ADDRESS:41040 LINCOLN STREETTELEPHONE:
(510) 656-4373
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:80CENSUS: 76DATE:
04/30/2026
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Divina Fernandez, Administrator TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not ensure that an appropriately skilled professional performs resident's glucose tests
Staff did not assist resident with obtaining medication
INVESTIGATION FINDINGS:
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On 04/30/2026 at 8:55 AM, Licensing Program Analyst (LPA) P. Manalo conducted an initial 10-day complaint visit and delivered the findings on the above allegations. LPA met with Administrator, Divina Fernadez and explained the purpose of the visit.

During the course of investigation, LPA interviewed 7 residents, 5 staff members, and witness. LPA reviewed and obtained the following documents including but not limited to Resident Roster, Personnel Report (LIC500), staff schedule, List of Residents on Special Diets, Medication Administration Record (MAR), medication order, After Visit Summary, Physician Report, Appraisal Needs and Services Plan, Email Correspondence, Food Menu, and staff certifications.

Continue to LIC9099-C…
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20260424121354
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: 04/30/2026
NARRATIVE
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Continued from LIC9099...

Allegation: Staff do not ensure that an appropriately skilled professional performs resident's glucose tests.

It was alleged that staff do not ensure that an appropriately skilled professional performs resident's glucose tests. Interview with 4 of 5 staff members stated that only skilled professionals are the ones performing the glucose test. Interview with ADM stated that there are nurses that work 7 days a week until 10:30 PM that can perform the glucose test and assist with other duties. However, interviews with 4 of 7 residents all stated that aside from the nurses, S2 or S4 will do the glucose tests for them. Based on record review, S2 and S4 are not skilled professionals and are not able to perform glucose monitoring tests.

Based on interviews and record review conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Allegation: Staff did not assist resident with obtaining medication.

It was alleged that Staff did not assist resident with obtaining medication. A review of email correspondence showed that Family Member 1 (FM1) sent an email to the facility’s email address that R1’s medication was ready on 04/17/2026. FM1 sent a follow email on 04/21/2026 and 04/23/2026 to see if the medication was picked up. Interview with ADM revealed that a staff member picked up the medication on Thursday, 04/23/2026. Interview with S4 showed that S4 talked to FM1 regarding the medication ready to be picked up at the pharmacy, but S4 did not pick it up until the following day. During today’s visit, LPA observed the medication bottle with a note that it was started on 04/23/2026.

Based on interviews and record review conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview was conducted with Administrator. A copy of this report and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/24/2026 and conducted by Evaluator Patricia Manalo
COMPLAINT CONTROL NUMBER: 15-AS-20260424121354

FACILITY NAME:LINCOLN VILLAFACILITY NUMBER:
019201495
ADMINISTRATOR:DIVINA FERNANDEZFACILITY TYPE:
740
ADDRESS:41040 LINCOLN STREETTELEPHONE:
(510) 656-4373
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:80CENSUS: 76DATE:
04/30/2026
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Divina Fernandez TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not follow resident's dietary plan
INVESTIGATION FINDINGS:
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On 04/30/2026 at 8:55 AM, Licensing Program Analyst (LPA) P. Manalo to conduct an initial 10-day complaint visit and deliver the findings on the above allegation. LPA met with Administrator, Divina Fernadez and explained the purpose of the visit.

During the course of investigation, LPA interviewed 7 residents, 5 staff members, and witness. LPA reviewed and obtained the following documents including but not limited to Resident Roster, Personnel Report (LIC500), List of Residents on Special Diets, Medication Administration Record (MAR), After Visit Summary, Physician Report, Appraisal Needs and Services Plan, Email Correspondence, Food Menu, and staff certifications.

Continue to LIC9099-C…
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20260424121354
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: 04/30/2026
NARRATIVE
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Continued from LIC9099-A...

Allegation: Staff do not follow resident's dietary plan.

It was alleged that staff do not follow resident's dietary plan. Interview with S3 revealed that S3 has a list in the kitchen of residents who are on special diets. During today’s visit, LPA observed that the kitchen has different plates for residents that is specified to their special diet. Interview with 4 of 7 residents all stated that they are receiving meals that are specific to their dietary plan that can include either low sugar, low sodium, or lactose free diets. Interview with 7 of 7 residents all indicated that they have no issues with the food that are being served to them.

Based on interviews and observations conducted, the above allegation that staff do not follow resident’s dietary plan is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

There is no deficiency noted.

Exit interview was conducted with Administrator, and a copy of this report was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20260424121354
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2026
Section Cited
CCR
87628(a)
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87628(a)Diabetes(a)The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing...or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
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By POC date, the Administrator agrees to self certify the regulation with staff members and send proof to CCLD by POC date. Moving forward, only appropriate skilled professionals will be the ones assisting or administering with glucose monitoring.
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Based on interviews, the licensee did not comply with the section cited above by having staff who are not skilled professionals assisting residents with glucose testing which poses a potential safety risk to persons in care.
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Type B
05/15/2026
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement is not met as evidenced by:
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By POC date, the Administrator will have an in-service meeting to ensure that the medications are picked up on time, make sure it's documented, and have a written order for all medications. Proof of correction will be sent to CCLD.
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Based on interview and record review, the licensee did not comply with the section cited above by not picking up the resident’s medication when it was ready for pick up 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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5