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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601280
Report Date: 03/10/2022
Date Signed: 03/10/2022 12:48:16 PM

Substantiated


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
03/08/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220308104946
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: 67DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Gina Velayo, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility heating and cooling system is in disrepair
INVESTIGATION FINDINGS:
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On 3/10/2022 at 9:20AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Administrator, Gina Velayo and informed her the reason for visit.

During the course of investigation, LPA interviewed 7 residents and 1 staff. Interview with residents revealed that R5's heater haven't been working since resident moved in about 2 weeks ago. LPA observed R5's heater has a broken button labeled "heat".

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D. Exit interview conducted. A copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
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
03/08/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220308104946

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: 67DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Gina Velayo, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
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9
Facility has roaches
INVESTIGATION FINDINGS:
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On 3/10/2022 at 9:20AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Administrator, Gina Velayo and informed her the reason for visit.

During the course of investigation, LPA interviewed 6 residents and 1 staff. LPA reviewed pest control invoices and observed that facility had pest control services since July 2018. Interview with residents revealed that there was cockroach issues, but facility have addressed it and have seen less cockroaches. Pest control was initially called on 9/16/2021 for cockroach issues. Invoices show that pest control was present to address the issue about every week or every other week since September 2021.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20220308104946
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation.
The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidence by:
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Administrator has agreed to repair R5's heater to be in operating condition by POC date. Administrator will send photo of the repair by POC date.
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Based on investigation, licensee did not comply with the section cited above by having inoperable heater which poses a potential health and safety risk to the persons in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3