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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002194
Report Date: 09/01/2021
Date Signed: 09/01/2021 12:47:41 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/08/2021 and conducted by Evaluator Melissa Lusby
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210208144217
FACILITY NAME:LINCOLN RESIDENCE 1408FACILITY NUMBER:
315002194
ADMINISTRATOR:ORDONA, RONFACILITY TYPE:
740
ADDRESS:1408 ALDER CREEK COURTTELEPHONE:
(916) 543-1338
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY:6CENSUS: 5DATE:
09/01/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Yas Patawaran, LicenseeTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident's needs are not being met
Facility does not follow proper sanitation
INVESTIGATION FINDINGS:
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LPA Lusby arrived on Wednesday September 1, 2021 to conclude a complaint investigation. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

Throughout the course of the investigation, LPA reviewed R1's physicians report, progress notes, admission agreement, and service plan. Additionally, LPA interviewed R1, Licensee, and facility staff. Based on the information obtained, the Department has concluded the above allegations to be unsubstantiated.

(continued on 9099-C)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Melissa Lusby
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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 2
Control Number 27-AS-20210208144217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: LINCOLN RESIDENCE 1408
FACILITY NUMBER: 315002194
VISIT DATE: 09/01/2021
NARRATIVE
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The Department finds the allegations of unmet resident needs and improper sanitation to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted. Appeal rights were printed and given. A copy of this report was left at the facility.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Melissa Lusby
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2