015601280-10-29-2024-15-AS-PMAO-DAHU7Y-20241029152044

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601280
Report Date: 10/29/2024
Date Signed: 10/29/2024 03:20:47 PM

Document Has Been Signed on 10/29/2024 03:20 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 VILLAGE		FACILITY NUMBER:	015601280
ADMINISTRATOR/ DIRECTOR:	GINA A VELAYO		FACILITY TYPE:	740
ADDRESS:	38801 HASTINGS STREET		TELEPHONE:	(510) 792-5411
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY: 120	TOTAL ENROLLED CHILDREN: 0	CENSUS: 57	DATE:	10/29/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:45 PM
MET WITH:	Gina Velayo, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

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Licensing Program Analyst (LPAs) Manalo and Clancy-Czuleger arrived unannounced to conduct a case management visit in response to the Unusual Incident Report (UIR) submitted by the facility. LPAs met with Administrator, Gina Velayo, and explained the purpose of the visit.

On 10/03/2024, R1 was sent to the hospital for an open wound on coccyx area. When discussing with Administrator, the wound got to this degree because R1 was not accepting care from facility staff. R1 was sent to Skilled Nursing Facility until wound healed and R1 was then readmitted to the facility.

No deficiency cited.

Exit interview conducted and copy of this report provided.

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

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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