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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200848
Report Date: 02/25/2025
Date Signed: 02/25/2025 01:59:34 PM

Document Has Been Signed on 02/25/2025 01:59 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 RTRMT COM-HAPPY LVNG BY COGIR/COGIR FREMONFACILITY NUMBER:
019200848
ADMINISTRATOR/
DIRECTOR:		KABADI, SANJAY PFACILITY TYPE:
740
ADDRESS:2860 COUNTRY DRIVETELEPHONE:
(510) 790-1645
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 40CENSUS: 37DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Salvador Gomez, Senior Executive Director TIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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On 02/25/2025 at 8:35 AM, Licensing Program Analysts (LPAs) P. Manalo and G. Luk arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Senior Executive Director, Salvador Gomez, and explained the purpose of the visit. The facility’s fire clearance was approved for forty (40) non-ambulatory and 3 hospice waiver.

LPAs toured the facility with Executive Director inside and out including but not limited to 6 residents' apartments, bathrooms, activity room, beauty salon, garden room, kitchen, common area and courtyard. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Two of Residents' temperature was maintained at 74 and 68 degrees Fahrenheit. The hot water temperature in a sample of residents’ room were measured at 115.9, 118.6, 115.3, 113.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid shower pan. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care.

Smoke detectors was last inspected on 01/10/2025. Carbon monoxide was in operating condition. Fire extinguisher was last serviced on 01/03/2025 all around the facility and in the kitchen. Emergency Disaster Plan was last posted on 02/25/2025. Emergency disaster drill was last conducted on 12/26/2024. Fire Drill was last conducted 01/30/2025. First aid kit was observed to be complete.

At 10:08 AM, LPAs reviewed 5 residents records. At 10:38 AM, LPAs reviewed 5 staff records and are associated to the facility. At 1:20 PM, LPAs reviewed a sample of resident’s medications.

Continue to LIC809-C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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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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 RTRMT COM-HAPPY LVNG BY COGIR/COGIR FREMON
FACILITY NUMBER: 019200848
VISIT DATE: 02/25/2025
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Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 03/05/2025:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance


THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 11:25 AM, LPAs observed during file review that S2 to S5 does not have First Aid Certificate.

At 12:00 PM, LPAs observed during file review that staff did not have documentation of training.

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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2025 01:59 PM - It Cannot Be Edited


Created By: Patricia Manalo On 02/25/2025 at 01:33 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 RTRMT COM-HAPPY LVNG BY COGIR/COGIR FREMON
FACILITY NUMBER: 019200848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(6)
Personnel Requirements - General
(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a review of the records, the licensee did not comply with the section cited above by not having training documentation for all staff which poses a potential health and safety risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Moving forward, Senior Executive Director agrees to have documentation for staff. Senior Executive Director agrees to self certify the regulation and send proof to CCLD by POC date.
Type B
Section Cited
CCR
87411(c)(1)
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

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 First Aid Certification for S2 to S5 which posses potential health and safety risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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Senior Executive Director agrees to have obtain First Aid Certification for staff and send proof 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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
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