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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708724
Report Date: 10/09/2026
Date Signed: 10/09/2026 11:24:50 AM

Document Has Been Signed on 10/09/2026 11:24 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LINCOLN & PINE, WILLOW GLENFACILITY NUMBER:
430708724
ADMINISTRATOR/
DIRECTOR:		BALTAZAR GUANZONFACILITY TYPE:
740
ADDRESS:1710 LINCOLN AVENUETELEPHONE:
(408) 265-6520
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 4DATE:
10/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator Baltazar GuanzonTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and follow up on an incident report regarding resident R1, wherin he/she eloped from the facility. LPA met with Administrator Baltazar Guanzon. During the visit, LPA observed 4 residents and 2 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms, 5 residents bedrooms and the basement. The staff area of the facility was also inspected. The front yard and backyard were inspected. While touring the home, LPA observed white lever lock, on the outside the hallway bathroom door handle. LPA asked ADM why this lock was there. ADM stated it was placed there because R1 wanders and tries to enter the bathroom at night. ADM removed the lock during the visit.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 72 degrees F, and hot water temperature was measured at 112 degrees F in resident bathrooms. Fire extinguisher was serviced in July 23, 2026. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on September 3, 2026. LPA reviewed facility disaster plan, which was last reviewed/updated on May 14, 2026. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. Page 1 Out of 3.
Romeo Manzano
Manuel Monter
DATE: 10/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: LINCOLN & PINE, WILLOW GLEN
FACILITY NUMBER: 430708724
VISIT DATE: 10/09/2026
NARRATIVE
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Elopement- September 26, 2026
On September 29, 2026, the Department received an incident report regarding resident R1. The incident report stated, On September 26, 2026 at 3:50 pm, staff S1 noticed that R1 is not in the facility. S1 went out to look for R1 and after an hour of not finding R1, S1 went back to the facility to call 911 for missing person. But then police car came and brought R1 back to the facility.

Attached to the incident report was a statement from staff S1 which stated the following: Staff S1 stated he/she was cooking in the kitchen. Staff S1 stated R1 and another resident were in the living room, and R1 briefly came in to check on staff S1 before leaving quietly. Staff S1 stated that around 3:50 p.m., while serving food, S1 noticed R1 was no longer in the living room. Staff S1 stated he/she checked the house and asked a coworker who was about to start their shift, but R1 was not inside the home. Staff S1 stated that's when they went to the front door, they saw the door alarm had been removed and began searching outside. Staff S1 stated he/she checked the yard and used a bicycle to search nearby streets but could not find R1. Staff S1 stated that around 5:00 p.m., he/she returned and saw police at the facility, who reported R1 had been found over a mile away. Staff S1 stated the police returned R1 safely by 5:30 p.m. Local Law Enforcement informed S1 that in less than an hour and thirty minutes ago someone called them and found R1 more than a mile away in the lane of Pine Ave going to Bird.

On September 28, 2026, LPA Manuel Monter contacted the facility and spoke with Administrator (ADM) Baltazar Guanzon. ADM stated he was not at the facility when the elopement occurred. ADM stated the care givers on duty were: (S1) and (S2) ADM stated, based on what S1 had told him, R1 came to check what S1 was doing while he/she was cooking, then left without S1 noticing.

ADM stated the last time R1 was seen was around 3:40-4:00pm. ADM stated the NOC shift will clock in at 4:00pm and go to break for an hour. ADM stated S1 looked for R1 outside the home and S2 stayed in the home. ADM stated R1 has neurocognitive disorder and cannot leave the facility unassisted. ADM stated R1 always has exit seeking behaviors, wanting to go home. ADM stated R1 is a wander. ADM stated R1 tries to leave at least once a day. ADM stated they installed an alarm on the door, which rings when opened. ADM stated R1 did not have any injuries. ADM stated R1's family has been informed. ADM stated the residents family were the ones initially contacted when R1 was found by the police. ADM stated R1 returned to the home at 5:30pm. Page 2 Out of 3
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: LINCOLN & PINE, WILLOW GLEN
FACILITY NUMBER: 430708724
VISIT DATE: 10/09/2026
NARRATIVE
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On October 9, 2026, Licensing Program Analyst Manuel Monter interviewed ADM Baltazar Guanzon. ADM stated R1 has exit seeking behaviors. ADM stated R1 will exit seek at least once a week.

The Department reviewed Resident R1's Preplacement appraisal, dated September 26, 2025 states R1 "needs special observation / night supervision (due to confusion, forgetfulness, wandering).

The Department reviewed Resident R1's Appraisal / Needs and Services Plan (ANS), dated August 22, 2026. The ANS states R1 has a neurocognitive disorder. ADM confirmed that this care plan is the newest care plan and has not updated the care plan.

The Department reviewed Resident R1's Physicians Report dated, September 19, 2025. The Physicians report states R1 has a neurocognitive disorder. Further more, the physicians report states R1 is not able to leave the facility unassisted. R1 also has a lack of hazard awareness.

As a result, the Department issued an immediate civil penalty of $500 for absence of supervision, which resulted in R1 eloping from the facility.

Deficiency cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

This report was reviewed with Administrator Baltazar Guanzon and a copy of the report was provided. Appeal Rights was provided.

Page 3 Out of 3. End of Report.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2026
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/09/2026 11:24 AM - It Cannot Be Edited


Created By: Manuel Monter On 10/09/2026 at 09:18 AM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LINCOLN & PINE, WILLOW GLEN
FACILITY NUMBER: 430708724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2026
Section Cited
CCR
87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services …to meet their needs.

This requirement was not met as evidence by:
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ADM stated she will submit a Plan of Correction outlining how he will ensure that residents who cannot leave the facility unassisted, have their supervision needs met. ADM stated he will submit the plan of action to LPA by POC due date October 11, 2026.
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Based on interviews & records reviewed, on September 26, 2026, resident R1 eloped from the facility unassisted. R1’s physician’s report dated September 19, 2025 states R1 has a neurocognitive disorder and cannot leave the facility unassisted. R1 was found alone by local law enforcement
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This pose/poses an immediate health, safety and personal rights risks to persons in care.
Type B
10/16/2026
Section Cited
CCR87463(a)

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87463 Reappraisals (a) The pre-admission appraisal…shall be updated in writing as frequently as necessary … to note significant changes in condition… and to keep the appraisal accurate. …shall be referred to as the reappraisal. This requirement is not met as evidenced by:
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ADM stated she will submit a written plan of action on how she will ensure residents care plans are updated in writing as frequently as necessary to note significant changes, and to keep the appraisal accurate. ADM stated he will submit the plan of action to LPA by POC due date October 16, 2026.
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Based on record review, R1’s Physician’s Report dated September 19, 2025 states R1 cannot leave the facility unassisted. ADM indicated that he has observed R1 exhibiting exit seeking behaviors. On September 26, 2026, R1 had eloped from the facility and was found by local law enforcement.
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 R1 was brought back to the home by Local law enforcement. R1’s care plan dated August 22, 2026, did not address the fact that R1 could not leave the facility unassisted and was not updated. This pose/poses a potential health, safety and personal rights risks to persons in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 10/09/2026 11:24 AM - It Cannot Be Edited


Created By: Manuel Monter On 10/09/2026 at 10:43 AM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: LINCOLN & PINE, WILLOW GLEN
FACILITY NUMBER: 430708724

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
87307 Personal Accommodations and Services (d) (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. While touring the home, LPA observed white lever lock, on the outside the hallway bathroom door handle. LPA asked ADM why this lock was there. ADM stated it was placed there because R1 wanders and tries to enter the bathroom at night. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2026
Plan of Correction
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ADM removed the white lever lock during the visit. ADM stated he will send a letter of understanding regarding the regulation. ADM stated he will submit the plan of correction by POC due date, October 16, 2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2026


LIC809 (FAS) - (06/04)
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