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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200941
Report Date: 09/17/2026
Date Signed: 09/17/2026 03:44:19 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/14/2026 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20260514093441
FACILITY NAME:LINCOLN GLEN ASSISTED LIVING CENTERFACILITY NUMBER:
435200941
ADMINISTRATOR:JAMES B MORTENSENFACILITY TYPE:
741
ADDRESS:2671 PLUMMER AVENUETELEPHONE:
(408) 267-4872
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:93CENSUS: DATE:
09/17/2026
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Administrator Melissa DocogTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff did not administer residents medication per physician's order
Staff did not ensure resident's incontinence needs were met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Administrator Melissa Docog

On May 14 2026, the Department received a complaint alleging Staff did not ensure resident's incontinence needs were met.

On May 20, 2026, the Department interviewed Witness W1. W1 stated he/she had arrived on March 9, 2026 at the facility around 9am, and found R1 severely soiled. W1 stated that was the first and only time he/she had found R1 severely soiled. W1 stated when he/she found R1 in this state, he/she contacted staff who helped change R1 immediately.

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Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
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 6
Control Number 26-AS-20260514093441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GLEN ASSISTED LIVING CENTER
FACILITY NUMBER: 435200941
VISIT DATE: 09/17/2026
NARRATIVE
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On May 20, 2026, Licensing Program Analyst Manuel Monter interviewed Resident Care Coordinator, referred to as Staff S1, and Staff S2–S5. S1 stated when it comes to changing residents, staff checks residents every 2 hours. 5 Out of 5 staff (S1-S5) stated they have never seen a resident who was neglected their incontinence needs/ left in a soiled state for an extended period.

On May 20, 2026, Licensing Program Analyst Manuel Monter interviewed residents R2-R4. 3 Out of 3 residents (R2-R4) stated they do not need assistance with using the restroom/ assistance with their incontinence needs.

On May 20, 2026, Licensing Program Analyst Manuel Monter interviewed Director of Health Services Scott Self, referred to as DHS. DHS stated he has not seen and or has not been notified of any instance where a residents toileting/incontinence needs were neglected.

On June 4, 2026 Licensing Program Analyst Manuel Monter interviewed staff S6-S9. 4 Out of 4 staff (S6-S9) stated they have never seen a resident who was neglected their incontinence needs/ left in a soiled state for an extended period.

On June 4, 2026, Licensing Program Analyst Manuel Monter interviewed Administrator (ADM) Melissa Docog. ADM she has never seen any instance where a resident was left soiled for an extended period. ADM stated residents are checked every 2 hours. ADM stated if any resident is observed soiled, they are changed. ADM stated if she see’s a resident soiled, she will inform the staff to have it addressed immediately.

On June 4 and 12, 2026, Licensing Program Analyst Manuel Monter interviewed residents R5-R12. 8 Out of 8 residents (R5-R12 ) stated they haven’t observed or is aware of any instance of a resident being soiled/neglected their toileting / showering needs.

The Department reviewed R1’s progress notes. Progress note dated March 1, 2026 states, staff S10 went in to change R1 , but it was clear that he/she had not been changed in a long time.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20260514093441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GLEN ASSISTED LIVING CENTER
FACILITY NUMBER: 435200941
VISIT DATE: 09/17/2026
NARRATIVE
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On June 15, 2026, Licensing Program Analyst Manuel Monter interviewed staff S10. S10 stated S10 stated he/she remembers this occurred sometime around the beginning of his/her NOC shift. S10 stated based on R1’s diapers appearance and smell, the soiled diaper was there for a long time. S10 stated this only occurred once, from what he/she remembers. S10 stated he/she honestly can’t remember other details of that day.

On June 19, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W2. W2 stated from his/her memory there have been at least 2 instances where he/she visited R1 in the morning and R1 appeared to have been left soiled for an extended period by the NOC shift. W2 stated he/she can't provide dates or details of these incidents as he/she does not recall.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

Staff did not administer residents medication per physician's order

On May 14, 2026, the Department received a complaint alleging Staff did not administer residents medication per physician's order

On May 20, 2026, the Department interviewed Witness W1. W1 stated R1’s pain medication was not administered. W1 stated staff are expected to provide pain medication on an as-needed (PRN) basis when R1 exhibits signs of pain. W1 stated that R1 is nonverbal and, during her time on hospice, was not considered capable of verbally communicating a need for PRN medication.

W1 stated based on text message exchange between him/herself and HSD, he/she believes HSD did not want to start a new pain medication for R1. LPA requested to review the text message exchange which are as follows: W1 asked if the facility would allow a new type of pain relief medication. HSD responded that he/she believed they should exhaust the current medications before adding more medications. HSD stated in his/her experience its too soon, and they need to see if the current medications are providing a proper therapeutic effect. Page 3 Out of 6
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20260514093441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GLEN ASSISTED LIVING CENTER
FACILITY NUMBER: 435200941
VISIT DATE: 09/17/2026
NARRATIVE
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W1 stated he/she had heard from a staff member (who he/she can’t recall), that the facility did not have a med tech on March 7 and March 8, 2026. LPA asked W1 if he/she was at the facility to confirm this. W1 stated he/she wasn’t there and this claim was based on what an unknown staff member had told him/her. The Department reviewed facility Timesheet Report which noted the facility had medtechs during each shift (morning, afternoon and NOC) for March 7 and March 8, 2026.

On May 20, 2026, Licensing Program Analyst Manuel Monter interviewed Resident Care Coordinator, referred to as Staff S1. S1 stated regarding R1’s medications (PRN), they follow the hospice orders. S1 stated if a resident is expressing pain, they will contact hospice and see if a PRN can be given. S1 stated R1’s family member (FM) would arrive to the facility and state R1 was in pain. S1 stated he/she would observe R1 sleeping and showing no signs of pain. S1 stated he/she would tell R1’s FM that R1 isn’t showing signs of pain. S1 stated regardless, they would contact hospice to get their disposition. S1 stated FM was expecting the facility to administer PRNs immediately once FM had requested, without calling hospice. S1 stated he/she knows a resident is in pain based on either verbal or non verbal communication. S1 stated the residents who can communicate will tell staff. S1 stated the residents who can’t verbally communicate, will grunt, react to touch, make noise, grimace their face.

On May 20, 2026, Licensing Program Analyst Manuel Monter interviewed staff S2- S5. 4 Out of 4 staff (S2-S5) stated they are not unaware of any instance where a resident was expressing pain, and staff neglected the resident expressing pain. 4 Out of 4 staff (S2-S5) stated they know when a non verbal resident is in pain based on their reactions such as: grunting, react to touch, make noises, grimacing their face.

On May 20, 2026, Licensing Program Analyst Manuel Monter interviewed residents R2-R4. 3 Out of 3 residents (R2-R4) stated they have not had any issues with their medication administration at the facility.

On May 20, 2026, Licensing Program Analyst Manuel Monter interviewed Director of Health Services Scott Self, referred to as DHS. DHS stated R1 is not able to vocalize his/her pain. DHS stated based on title 22, they must follow the hospice agreement and if it seems like R1 is expressing pain, they will contact the hospice Agency. Page 4 Out 6
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 26-AS-20260514093441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GLEN ASSISTED LIVING CENTER
FACILITY NUMBER: 435200941
VISIT DATE: 09/17/2026
NARRATIVE
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DHS stated there was also instances where R1's FM would note R1 being in pain, then staff would enter R1’s bedroom and R1 was not showing, expressing or providing signs that R1 need a PRN. DHS stated they would call hospice to have them make the determination. DHS stated R1’s FM didn’t understand this. DHS stated the facility did not refuse to administer medications as per doctors orders. DHS stated staff never refused to administer R1’s medication.

LPA interviewed HSD regarding the text message exchanges between him/herself and W1. HSD stated he/she was not refusing to start a new pain medication for R1. HSD stated he/she was only posing a question, asking if sufficient time had passed for the current medications prescription’s take effect and see if they are having the proper therapeutic effect.

On June 4, 2026 Licensing Program Analyst Manuel Monter interviewed staff S6-S9. 4 Out of 4 staff (S6-S9) stated they are not unaware of any instance where a resident was expressing pain, and staff neglected the resident expressing pain. 4 Out of 4 staff (S6-S9) stated they know when a non verbal resident is in pain based on their reactions such as: grunting, react to touch, make noises, grimacing their face.

On June 4, 2026, Licensing Program Analyst Manuel Monter interviewed Administrator (ADM) Melissa Docog. ADM stated if a resident is not able to express or assess their own pain, the staff will need to observe if there is any signs of discomfort. ADM stated if staff observes a resident moaning, shifting around, grimacing or expressing pain, then they will inform the medtech, who will inform the health services director. ADM stated if a resident is under hospice, they will inform them. ADM stated she is aware that R1’s FM was having ongoing issues with the medtechs, the RCC and the health services director. ADM stated the FM would visit R1 and would state that R1 was in pain. ADM stated the health services director would see R1 and R1 was not expressing pain.

On June 4 and 12, 2026, Licensing Program Analyst Manuel Monter interviewed residents R5-R12. 7 Out of 8 residents (R5 - R7, R9-R12 ) stated they have not had any issue with their medication administration. R8 stated he/she manages his/her own medication and does not require assistance.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20260514093441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GLEN ASSISTED LIVING CENTER
FACILITY NUMBER: 435200941
VISIT DATE: 09/17/2026
NARRATIVE
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On June 19, 2026, Licensing Program Analyst Manuel Monter interviewed Witness W2. W2 stated resident R1 cannot determine his/her own need for PRN medication and cannot communicate his/her symptoms, indicating a need for PRN medication. W2 stated he/she was aware there have been instances where R1's FM stated R1 was in pain, but R1 did not express pain. W2 stated in instances where R1 was expressing pain, PRN medication was administered.

On September 17, 2026, Licensing Program Analyst Manuel Monter interviewed ADM Melissa Docog, Health Services Director and Staff S1. ADM, HSD and S1 stated they have never observed R1's legs off the bed, resting on the heater/air conditioner, or R1 kicking off his/her comforter/socks. ADM, HSD and S1 stated R1 did not have any behaviors regarding leg movement. ADM, HSD and S1 stated R1 would typically lay on his/her bed and his/her legs would be straight or he/she would lay on her/side with his/her legs in a slight fetal position.

The Department reviewed R1’s progress notes. Progress note dated March 7, 2026 states, R1’s hospice nurse was sent to conduct a condition check due to R1’s FM’s concerns. It was reported FM wanted to increase frequency of pain medication. Upon examination, hospice nurse agreed that R1 was asleep comfortably and notified the facility they would not change the frequency orders for PRN M1 and PRN M2 .

Progress note dated March 8, 2026 states R1 had a visit from hospice nurse regarding pain management. Per Hospice nurse, he/she was contacted by R1’s FM, stating R1 was in pain. Hospice nurse assessed R1 appearing comfortable, no facial grimacing, no moans/groans.

Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6