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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601280
Report Date: 07/15/2021
Date Signed: 07/15/2021 03:22:33 PM

Document Has Been Signed on 07/15/2021 03:22 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:FREMONT VILLAGEFACILITY NUMBER:
015601280
ADMINISTRATOR:GINA A VELAYOFACILITY TYPE:
740
ADDRESS:38801 HASTINGS STREETTELEPHONE:
(510) 792-5411
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 120CENSUS: 59DATE:
07/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Gina Velayo, Executive DirectorTIME COMPLETED:
03:30 PM
NARRATIVE
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On 7/15//2021 at 1:05PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a case management visit regarding an incident report received on 7/9/2021. LPA met with Executive Director, Gina Velayo and explained the reason for the visit.

Incident report dated 7/8/2021 revealed that R1 AWOL'd and facility notified R1's responsible party. R1 was found by On-Lok driver approximately one (1) hour later and escorted to the clinic,

Interviews with staff revealed that R1 left the facility during the afternoon bingo activity. S1 stated that facility staff looked for resident inside, outside and in the neighborhood, but unable to find R1. Staff noticed a window in the dining room was open, screen was torn, a chair placed in front of the window, and determined that is where R1 exited the facility. R1 was brought back to the facility from the clinic.

S1 was able to provide LPA with physician's report for R1. S1 did not have any other records for R1. LPA requested the following documents: admission agreement, pre-placement assessment, and appraisal needs and services

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalty.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2021
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 2
Document Has Been Signed on 07/15/2021 03:22 PM - It Cannot Be Edited


Created By: Laura Hall On 07/15/2021 at 02:50 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FREMONT VILLAGE
FACILITY NUMBER: 015601280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2021
Section Cited
CCR
87468.1(a)(2)

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87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe... accommodations .. This requirement was not met as evidence by:
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Executive Director agreed to have a new AWOL procedure and submit a copy to CCLD by POC date.
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Based on LPA's interviews licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care.
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Type B
07/22/2021
Section Cited
CCR87506(a)

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87506 Resident Records (a) The licensee shall ensure that a... current record is maintained for each resident in the facility... to licensing agency staff. The requirement was not met as evidence by:
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Executive Director agreed to submit a copy of R1's admission agreement, pre-placement assessment, and appraisal needs and services to CCLD by POC date.
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Based on LPA's record review licensee did not comply with the section cited above which poses a potential health and 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2