015601280-4-9-2026-15-AS-BFOG-DTCVHD-20260421162658

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601280
Report Date: 04/09/2026
Date Signed: 04/09/2026 03:43:37 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/06/2025 and conducted by Evaluator Patricia Manalo

COMPLAINT CONTROL NUMBER: 15-AS-20250806080132

FACILITY NAME:	FREMONT VILLAGE		FACILITY NUMBER:	015601280
ADMINISTRATOR:	GINA A VELAYO		FACILITY TYPE:	740
ADDRESS:	38801 HASTINGS STREET		TELEPHONE:	(510) 792-5411
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	120	CENSUS: 66	DATE:	04/09/2026
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Gina Velayo, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Personal Rights - Lack of care and supervision resulted in resident sustaining a fracture.
Personal Rights - Resident was inappropriately restrained while in care.
Personal Rights - Staff did not notify responsible party of incident.

INVESTIGATION FINDINGS:

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On 04/09/2026 at 9:20 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to continue the investigation on the above allegations and deliver findings for the complaint. LPA met with Administrator, Gina Velayo and explained the purpose of the visit.

During the course of the investigation, the Department obtained and reviewed the following documents including but not limited to Resident Roster, Staff Roster, Staff Schedule, Admission Agreement, Identification and Emergency Information, Physician’s Report, Preplacement Appraisal, Appraisal Needs and Services Plan, Physician’s Fax Reports, After Visit Summary, Unusual Incident Reports, Facility Visitor Logs, Email Correspondence, Power of Attorney Documentation, Immunization Record, On Lok PACE Level of Care Assessment Tool, On Lok PACE Care Plan, Physician Orders for Life-Sustaining Treatment (POLST), On Lok Fall Incident Report, Facility’s Behavior Log, Communication Log Memory Care Unit, Resident Notes, Resident Communication Log, SOC341, Fall Incident Report Fax Cover Sheet, and photos of the resident’s injury.
Continue to LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

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 4

Control Number 15-AS-20250806080132

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/09/2026

NARRATIVE

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... Continued from LIC9099...

The Department conducted interviews with facility residents, staff, and witnesses. On 04/09/2026, LPA P. Manalo conducted additional interviews with staff, residents, and witnesses and obtained the following documents included but not limited to an updated staff roster, resident roster, and Personnel Report (LIC500).

Allegation: Lack of care and supervision resulted in resident sustaining a fracture.

It was alleged that lack of care and supervision resulted in resident sustaining a fracture. A review of facility’s resident notes dated 05/10/2024 showed that S1 found R1 sitting on the floor holding their head due to an unwitnessed fall during S1’s last rounds. A review of On Lok Fall Incident Report dated 05/10/2024 revealed that S1 immediately called 911 and R1 was transported to the hospital.

Interview conducted by the Department revealed that R1 was not a fall risk per W1. Interview with S1 revealed that R1 was able to walk on their own and would hardly use their assistive device when walking around the facility. S1 stated that when S1 was conducting their last rounds on 05/10/2024, S1 found R1 on the floor. S1 proceeded to call 911 and R1 was taken to the hospital. 3 of 3 staff members all stated that R1 was able to walk on their own independently. The Department obtained and reviewed an intake assessment dated 4/18/24 indicating that R1 was not a fall risk and could ambulate and transfer independently. The physician report dated 4/18/24 did not indicate a mobility concern nor that assistance was needed for this issue. The Department further found that there were no other falls preceding the incident of 5/10/24. No other corroborating evidence was obtained to support the allegation.

Based on the investigation, which included interviews and record reviews, the allegation that lack of care and supervision resulted in resident sustaining a fracture is unsubstantiated. Although the concern was reported, there is insufficient evidence to confirm the allegations. Records reviewed were consistent with interviews, and no corroborating evidence was obtained to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time.

Continue to LIC9099-C...

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20250806080132

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/09/2026

NARRATIVE

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... Continued from LIC9099-C...

Allegation: Resident was inappropriately restrained while in care.

It was alleged that resident was inappropriately restrained while in care. Per email from W1, it seemed like there were signs of restraint and bruises from the fall. On 12/08/2025, the Department received an SOC341 to further describe that W1 thinks that R1 was abused and R1’s legs were tied up.

On 04/09/2026, LPA P. Manalo interviewed 9 staff members that all indicated that they have not observed or witnessed any residents restrained while in care. Interview with W5 verified that they come to the facility on monthly basis to check on their residents that are part of the Onlok Pace Program and have not observed any staff restraining residents. 5 of 12 residents interviewed stated that staff do not tie them up. LPA attempted to interview 7 of 12 residents and could not obtain information. LPA interviewed additional witnesses in which 2 of 2 witnesses revealed that they have not witnessed any staff restraining residents or seen the residents tied up inappropriately.

Based on the investigation, which included staff interviews and review of available documentation, the allegation that resident was inappropriately restrained while in care is unsubstantiated. Although the concern was reported, there is insufficient evidence to confirm the allegation. Statements obtained during the investigation were inconsistent, and no corroborating evidence was found to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time.

Allegation: Staff did not notify responsible party of incident.

It was alleged that staff did not notify responsible party of incident. W1’s email indicated that the facility did not notify them of the fall. However, a review of the physician’s fax report from the facility indicated that the facility called 911, notified the On Lok Pace Program, and informed W2 of the incident. A review of the facility’s communication log dated 05/10/2024 revealed that an unknown staff member spoke with W2 via text message that R1 sustained an arm fracture and will be staying in the hospital per W2.

Continue to LIC9099-C...

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20250806080132

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/09/2026

NARRATIVE

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... Continued from LIC9099-C...

In addition, S1 reported the incident using On Lok Pace’s Incident Report document dated 05/10/2024 that included that W2 and W4 were notified. Interview conducted by the Department revealed that W1 received a call from the facility that informed W1 of R1’s fall and that R1 was heading to the hospital. On 04/09/2026, LPA P. Manalo spoke with W3 that confirmed W4 spoke with S1 on May 10, 2024, of R1’s fall. Per W3, it was documented on the Onlok Pace system that W4 was notified of R1’s incident on that day. W2 also confirmed that W2 was notified of R1’s fall and that R1 was on the way to the hospital. In addition, interview with 5 of 5 staff members stated that if they observe any incidents, they will notify the Medication Technician (Medtech) on shift of the incident and the Medtech will be the ones to notify the appropriate parties. Interviews with 3 of 3 staff members all confirmed that whenever there are incidents, the facility will notify the family and/ or responsible party, Onlok Providers, and resident’s physician.

Based on the investigation, which included staff interviews and review of available documentation, the allegation that staff did not notify responsible party of incident is unsubstantiated. Although the concern was reported, there is insufficient evidence to confirm the allegation. Statements obtained during the investigation were inconsistent, and no corroborating evidence was found to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time.

There is no deficiency noted.

Exit interview was conducted with Administrator, and a copy of this report was provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026

LIC9099 (FAS) - (06/04)

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