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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200761
Report Date: 01/13/2023
Date Signed: 01/13/2023 12:46:32 PM

Document Has Been Signed on 01/13/2023 12:46 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 HILLSFACILITY NUMBER:
019200761
ADMINISTRATOR:BERNADETTE MILOFACILITY TYPE:
740
ADDRESS:35490 MISSION BLVDTELEPHONE:
(510) 796-4200
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 140CENSUS: 68DATE:
01/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:BERNADETTE MILO- Administrator TIME COMPLETED:
01:00 PM
NARRATIVE
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On 1/13/2023, at 12:10PM, Licensing program analysts (LPAs) L. Fici And C. Lin arrived unannounced to conducted a case management about an incident that the LPA was informed about. LPAs met and was greeted by Administrator, BERNADETTE MILO and explained the purpose of the visit.

On 1/11/2023, LPA was informed of an incident at the facility occurred on 12/31/2022 and the administrator failed to submit an Lic624 to CCL. Administrator emailed LPA an Lic624 regarding the incident that occurred on 1/11/2023. LPAs discussed with administrator the regulation on reporting requirements to be submitted to CCL on a timely manner.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Deficiency is being cited due to reporting requirements


Exit interview conducted with administrator, appeal rights given with a copy of this report.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Liridon Fici
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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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Document Has Been Signed on 01/13/2023 12:46 PM - It Cannot Be Edited


Created By: Liridon Fici On 01/13/2023 at 12:31 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 HILLS
FACILITY NUMBER: 019200761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2023
Section Cited
CCR
87211(a)(1)

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87211(a)(1) Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...
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Administrator agreed to conduct a in-service training on the regulation Reporting Requirements and to have staff sign the in-service training and to submit to CCL by POC due date.
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This requirement is not met as evidenced by:

Based on interview and record review, the administrator did not comply with the section cited above by not reporting an incident to CCL within 7 days of the occurrence which poses a potential health, safety or personal rights 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Liridon Fici
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023


LIC809 (FAS) - (06/04)
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