015601280-1-6-2022-15-AS-KHOS-CBBJWE-20220204062436

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601280
Report Date: 01/06/2022
Date Signed: 01/06/2022 01:37:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/13/2020 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200413165331

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: 61	DATE:	01/06/2022
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Gina Velayo, Executive Director		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Personal Rights - Staff neglect resulting in death of resident.
Personal Rights - Facility failed to notify responsible party

INVESTIGATION FINDINGS:

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On 1/6/2022 at 12:50 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegations. LPA met with Executive Director, Gina Velayo and explained the purpose of the visit.

During the course of the investigation, LPA L. Francisco obtained information, collected documents and interviewed 2 staff. LPA Y. Flores-Larios collected documents on 4/16/2021 and interviewed witness .

Allegation: Staff neglect resulting in death of resident

Based on information obtained by complainant, R1 was observed wearing a shirt, socks and diaper, and pendant was not accessible to resident because it is tied around the rails.

***REPORT CONTINUES ON 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200413165331

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: FREMONT VILLAGE	FACILITY NUMBER: 015601280
	VISIT DATE: 01/06/2022

NARRATIVE

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However, based on interview with S1, S1 stated resident has a history of refusing to be clothed in pajama pants. S1 added the pendant is tied around the rails because R1 did not want it around R1's neck. However, it was within R1s reach. Based on record review, on 3/26/2020, the day of the incident, R1 vomited, and was cleaned and changed by a caregiver on shift. S2 does not recall caregiver's name. When S2 was informed of R1's condition, S2 observed R1 gasping for air and immediately called 9-1-1.

Allegation: Facility failed to notify responsible party

Based on information obtained by complainant, complainant received a call from local law enforcement and was not contacted by facility. However, LPA obtained a copy of the incident report noting that facility had contacted R1's responsible party.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022

LIC9099 (FAS) - (06/04)

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