<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601280
Report Date: 09/29/2022
Date Signed: 09/29/2022 02:36:00 PM


Document Has Been Signed on 09/29/2022 02:36 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 VILLAGEFACILITY NUMBER:
015601280
ADMINISTRATOR:GINA A VELAYOFACILITY TYPE:
740
ADDRESS:38801 HASTINGS STREETTELEPHONE:
(510) 792-5411
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:120CENSUS: 65DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Gina A Velayo, AdministratorTIME COMPLETED:
02:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/29/2022, at 1:40 PM, Licensing Program Analyst (LPAs) L. Fici and C. Lin arrived unannounced to conduct Infection Control Inspection. LPAs met with Gina A Velayo, administrator (ADM) and explained the purpose of the visit.

During the inspection, LPAs toured facility including but not limited to common areas, hand washing stations, bedrooms, bathrooms, kitchen and courtyard. LPAs observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPAs observed PPE's are sufficient. Food and paper supplies are sufficient. Hand sanitizer is provided at facility entrance. Water temperature is measured at 109.3 degrees F. Fire extinguisher was last serviced on March 23, 2022. LPAs observed facility passages inside and out are free of obstruction. Smoke and carbon monoxide detectors were observed and maintained. Common areas are disinfected 3 times a day.

During record review, LPAs observed facility has a copy of Mitigation Plan and emergency disaster plan on file.

No deficiencies cited during visit. Exit interview conducted with ADM and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1