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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601280
Report Date: 12/03/2024
Date Signed: 12/03/2024 01:27:44 PM

Document Has Been Signed on 12/03/2024 01:27 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:FREMONT VILLAGEFACILITY NUMBER:
015601280
ADMINISTRATOR/
DIRECTOR:		GINA A VELAYOFACILITY TYPE:
740
ADDRESS:38801 HASTINGS STREETTELEPHONE:
(510) 792-5411
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 120CENSUS: 60DATE:
12/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Gina Velayo, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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On 12/03/2024 at 1:00 PM Licensing Program Analysts (LPAs), P. Manalo and K. Nguyen arrived unannounced to conduct a case management following up an incident that was reported to CCLD on 11/11/2024. LPAs met with Administrator, Gina Velayo, and explained the reason for the visit.

LPAs reviewed R1's Physician's Report, Appraisal Needs and Service Plan, and Discharge Summary. LPAs requests for an updated Physician's Report due to resident's new health condition.

LPAs will send the requested documents to CCLD by 12/13/2024:
  • Updated Physician's Report and current Physician's Report
  • Discharge Summary
  • Care Notes
  • Appraisal Needs and Services Plan
  • Documentation's of POA
  • November Staff Schedule
  • Staff Contacts


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.



SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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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