015601280-11-14-2023-15-AS-KHOS-CY2SC6-20231129124500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601280
Report Date: 11/14/2023
Date Signed: 11/14/2023 04:14:36 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
06/28/2023 and conducted by Evaluator Liridon Fici

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230628110054

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: 59	DATE:	11/14/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Gina A, Velayo- Administrator		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Staff spoke inappropriately to resident in care.
Staff did not assist resident with hygiene needs.
Staff did not seek dental care for resident in a timely manner.
Staff not ensuring resident's room is clean.

INVESTIGATION FINDINGS:

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On 11/14/2023, at 1:45 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a subsequent complaint investigation visit and to deliver findings on the above allegations. LPA met with Gina A, Velayo- Administrator (ADM) and explained the purpose of today’s visit.

During the course of the investigation, LPA interviewed six (6) residents, and seven (7) staff members. LPA requested and obtained the following documents: Staff roster with contact information, Physicians reports, residents care plan log (October 2020, June 2023, July 2023), dental care plan, admission agreement, progress notes for (October 2020, June 2023).

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023

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-20230628110054

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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
	VISIT DATE: 11/14/2023

NARRATIVE

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It was alleged that, staff spoke inappropriately to resident in care, and staff did not assist resident with hygiene needs. Based on interviews and record review conducted, all 7 staff stated that activities of Daily Living (ADLs) are being done for residents in the morning, and in the afternoon. LPA reviewed residents care plan log and housekeeping log which indicated that staff are cleaning the residents’ room including the bathrooms to make sure it is clean and sanitized for residents use. LPA confirmed with residents’ during interview that staff do come in to clean their rooms and bathrooms to make sure its clean.

It was alleged that; staff did not seek dental care for resident in a timely manner. Based on interviews and record review conducted, staff stated to LPA that On Lok will schedule dental appointments for some residents’. Staff will also contact On Lok to schedule dental appointments as well for residents’ to be seen for dental care. During interview with residents’, residents stated that staff will contact On Lok to schedule dental appointments for residents to be seen and sometimes the family of the residents will schedule dental appointments for residents. LPA reviewed R1’s dental records, which indicated that R1 has been seen frequently by the dental providers since 2021 and continues to be seen by dental providers.

It was alleged that, staff not ensuring resident's room is clean. Based on interviews and observation conducted, all staff stated that residents rooms are clean in the morning and afternoon, or as needed. R1- R6 stated staff clean residents’ rooms. On November 14, 2023, LPA observed that the residents bathrooms are kept clean and sanitary for the use of the residents.

Based on Interviews record review conducted, Although the allegation may have happened or are 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 with ADM, and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023

LIC9099 (FAS) - (06/04)

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