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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 02:04:37 PM

Document Has Been Signed on 02/25/2025 02:04 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:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Salvador Gomez, Senior Executive Director TIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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On 02/25/2025 at 1:25 PM, Licensing Program Analysts (LPAs) P.Manalo G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 02/24/2025. LPAs met with Senior Executive Director, Salvador Gomez, and explained the purpose of the visit.

Unusual Incident Report indicated that R1 was having difficulty breathing and was sent to the hospital on 02/13/2025. Death Report indicated that R1 passed away at the hospital 02/20/2025.

LPAs interviewed Senior Executive Director and stated that R1 was in the process of moving to another facility to obtain higher level of care and going into hospice services.

No deficiencies are being cited on this date.


Exit interview conducted. 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
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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