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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601280
Report Date: 09/22/2025
Date Signed: 09/22/2025 02:18:49 PM

Document Has Been Signed on 09/22/2025 02:18 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: 64DATE:
09/22/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Gina Velayo, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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On 09/22/2025 at 9:10 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct 1-Year Annual-Continuation Required inspection. LPA met with Administrator, Gina Velayo and explained the purpose of the visit.

On 09/19/2025, LPAs toured the facility inside and out including but not limited to 10 residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 74 degrees F. The hot water temperature in a sample of residents’ shared bathrooms were measured at 109.8, 94.4, 89.8, 90, and 93.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats and non-skid shower pan.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 03/07/2025. Emergency Disaster Plan was last posted on 01/20/2025. First aid kit was observed to be complete. Fire drill was last conducted on 05/04/2025.

On 09/19/2025 at 10:28 PM, LPA reviewed 7 residents records. At 11:20 AM, LPAs reviewed 6 staff records. 6 of 6 staff have current first aid training and are associated with the facility. At 3:04 PM, LPAs reviewed 3 samples of residents’ medications.

Continue to LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2025
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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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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Document Has Been Signed on 09/22/2025 02:18 PM - It Cannot Be Edited


Created By: Patricia Manalo On 09/22/2025 at 11:43 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FREMONT VILLAGE
FACILITY NUMBER: 015601280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above by having items including but not limited to disinfectant spray, acetone nail polish remover, Arm & Hammer Odor Blaster, laundry detergent, Lysol spray, etc., in multiple areas at the facility unlocked and accessible to residents' in care which poses an immediate safety risk to persons in care.
POC Due Date: 09/23/2025
Plan of Correction
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The Administrator agrees to self-cetify the regulation and locked the items. Proof of correction will be sent to CCLD by POC date.
Type A
Section Cited
CCR
87309(c)
Storage Space and Access
(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having items including but not limited to hydrocortisone cream, Ketoconazole 2% shampoo, prescribed cerave face wash, saline wound cleanser, One Day Vitamin, insulin, etc., in residents' room unlocked and accessible to residents' in care which poses an immediate safety risk to persons in care.
POC Due Date: 09/23/2025
Plan of Correction
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The Administrator agrees to self-certify the regulation and locked the items. Proof of correction will be sent to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2025


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 09/22/2025 02:18 PM - It Cannot Be Edited


Created By: Patricia Manalo On 09/22/2025 at 11:43 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FREMONT VILLAGE
FACILITY NUMBER: 015601280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having items in disrepair such as dresser handle, ac in the memory care unit, air conditioning in the dining hall, dirty showers, resident’s toilet covered in feces, dirty showers. LPAs also observed items such as foul odor, washing machine, portable heaters, broken toilet, old mattress left out which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2025
Plan of Correction
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The Administrator agrees to ensure the facility is in good repair and sanitary. Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having the hot water temperature measured within range which poses a potential safety risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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The Administrator agrees to have the water temperature measured within range and send proof of correction to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2025


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 09/22/2025 02:18 PM - It Cannot Be Edited


Created By: Patricia Manalo On 09/22/2025 at 11:43 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FREMONT VILLAGE
FACILITY NUMBER: 015601280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by multiple boxes of sugar dated 05/01/2019 and expired in 2021, canned goods and opened pasta not properly labeled. LPAs also observed mineral oil in a Purell Surface Disinfectant Spray bottle which poses a potential health and safety risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
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The Administrator agrees to throw out the expired food and self certify the regulation with kitchen staff. Proof of correction will be sent to CCLD by POC date.
Type B
Section Cited
CCR
87463(i)
Reappraisals
(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having an updated Appraisal Needs and Services Plan (LIC625) for R1, R2, R4, and R7 which poses a potential health and safety risk to persons in care.
POC Due Date: 10/06/2025
Plan of Correction
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The Administrator agrees to submit an updated LIC625 for the residents and ensure all residents have an updated LIC625. Proof of correction will be sent to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/22/2025 02:18 PM - It Cannot Be Edited


Created By: Patricia Manalo On 09/22/2025 at 01:03 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: 09/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having a resident's family member reside in the resident's room which poses a potential personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
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The Administrator agrees to come up with a plan for the residents' visitors staying overnight and send proof to CCLD by POC date.
Type B
Section Cited
CCR
87465(h)(5)
(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 by medications prepoured to be administered the following day which poses a potential health and safety risk to persons in care.
POC Due Date: 10/06/2025
Plan of Correction
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The Administrator agrees to conduct an in-service on stopping the prepouring for medications and submit to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2025


LIC809 (FAS) - (06/04)
Page: 9 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FREMONT VILLAGE
FACILITY NUMBER: 015601280
VISIT DATE: 09/22/2025
NARRATIVE
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Continue from LIC809...

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

On 09/19/2025 at 3:23 PM, LPAs observed multiple boxes of sugar dated 05/01/2019 and expired in 2021. LPAs observed canned goods and opened pasta not properly labeled. LPAs observed mineral oil in a Purell Surface Disinfectant Spray bottle.

On 09/19/2025, starting at 9:20 AM, LPAs observed broken toilet, mattress, holes in memory care resident's room, broken dresser handle, resident's toilet covered in feces, dirty shower, air condition, washing machine, portable heaters in the library area on second floor, etc. LPAs observed odor in resident's room and the air conditioning broken in the dining hall.

On 09/19/2025 at 1:00 PM, LPAs observed the hot water temperature measured between 89.8 degrees F and 94.4 degrees Fahrenheit.

On 09/19/2025 starting at 2:41 PM, LPAs observed disinfectant spray, acetone nail polish remover, Arm & Hammer Odor Blaster, laundry detergent, Lysol spray, etc., in multiple areas at the facility unlocked and accessible to residents' in care.

On 09/19/2025 starting at 2:41 PM, LPAs observed hydrocortisone cream, Ketoconazole 2% shampoo, prescribed cerave face wash, saline wound cleanser, One day Vitamin, etc., in residents' room unlocked and accessible to residents' in care.

On 09/19/2025 at 3:45 PM, LPAs observed pre-poured medication in the janitor's room. Interview with Assistant Administrator revealed that medications was pre-poured for the next day.

On 09/19/2025 at 3:47 PM, LPAs observed resident's family member residing in the resident's room

Continue to LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
LIC809 (FAS) - (06/04)
Page: 11 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: FREMONT VILLAGE
FACILITY NUMBER: 015601280
VISIT DATE: 09/22/2025
NARRATIVE
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Continue from LIC809-C...

On 09/22/2025 at 11:30 AM, LPAs observed that that R1, R2, R4, and R7 does not have an updated LIC625 Appraisal Needs and Services Plan.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
LIC809 (FAS) - (06/04)
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