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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005690
Report Date: 07/29/2021
Date Signed: 07/29/2021 04:32:11 PM

Document Has Been Signed on 07/29/2021 04:32 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:LINCOLN MANORFACILITY NUMBER:
397005690
ADMINISTRATOR:MANZANO, MARY ANNFACILITY TYPE:
740
ADDRESS:934 KATHERINE WAYTELEPHONE:
(209) 513-8913
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 6CENSUS: 3DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Mary Ann Manzano, Facility AdministratorTIME COMPLETED:
02:10 PM
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On 07/29/21 at 11:45 AM, LPA Bruce Jacobs arrived at this facility unannounced to conduct an annual inspection visit. LPA was met by care staff who informed Administrator Mary Ann Manzano the LPA' s visit. LPA explained the purpose of the visit and Mary Ann accompanied LPA on the facility inspection. Administrator's Certificate for M. Manzano # 6021224740 expires 10/23/22.

LPA Jacobs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 3 clients and 4 bedrooms and two bathrooms. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. The hallway has COVID precautions in place including social distancing noted. Medications and toxins noted to be locked to residents in care. LPA also conducted the infection control domain tool.

The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

LPA observed the facility to have adequate food supply of 7 days non-perishables and 2-days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: LINCOLN MANOR
FACILITY NUMBER: 397005690
VISIT DATE: 07/29/2021
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The facility common areas were clean and furnished. Smoke and carbon detectors were tested and are operational and in good repair. Fire extinguishers were serviced in July 2021 and are in compliance. All staff on-site have current fingerprint clearances.

LPA requested the following documents to be updated: LIC 500 and LIC 309 as needed.

Per California Code of Regulations, Title 22 no deficiencies were observed during this visit. Exit interview was held and a report was issued Mary Ann Manzano..
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC809 (FAS) - (06/04)
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