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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601280
Report Date: 04/11/2024
Date Signed: 04/11/2024 03:41:42 PM


Document Has Been Signed on 04/11/2024 03:41 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: 55DATE:
04/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Gina VelayoTIME COMPLETED:
04:00 PM
NARRATIVE
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On this day at around 3:30pm, Licensing Program Analysts (LPAs) Luisa Fontanilla and Kelly Nguyen arrived unannounced to conduct a case management visit and met with Gina Velayo. LPA explained to Velayo the purpose of the visit.

During the course of investigation of complaint # 15-AS-20230718143211, the Department conducted interviews and reviewed records. Based on interviews conducted, S1 found R1 unconscious at 5 am and called S2 immediately. LPA interviewed S2 who states that S2 responded and went to R1’s room which is on the 2nd floor of the building using the elevator. Once S2 was in R1’s room and saw R1, S2 went downstairs to check R1’s file if R1 has Do Not Resuscitate (DNR). When asked by LPA if S2 performed CPR to R1, S2 does not recall because the incident happened so fast and he “blacked out” but remembered calling S3, another Medication Technician on shift. S1 and S2 both state S3 performed CPR on R1.

S2 placed the 911 call recorded at 5:21 am.

Deficiency is cited per Title 22 California Code of Regulations. Failure to correct the cited deficiency on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.


SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
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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Document Has Been Signed on 04/11/2024 03:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2024
Section Cited
CCR
87465(g)

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87465(g) Incidental Medical and Dental Care
(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
This requirement is not met as evidenced by: Based on interviews and record reviews conducted, 1) S2 failed to perform CPR for R1 immediately 2) the facility failed to call 911 immediately for R1. R1 was found unresponsive at 5am, 911 call was placed at 5:21 am.
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The Administrator will conduct inservice for all staff on the facility's emergency procedures and submit proof of training to CCL by POC date.
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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