015601280-4-11-2024-15-AS-YFLS-D64W3V-20240610165633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601280
Report Date: 04/11/2024
Date Signed: 04/11/2024 03:40:41 PM

Unsubstantiated

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
07/18/2023 and conducted by Evaluator Luisa Fontanilla

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230718143211

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: 55	DATE:	04/11/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Gina Velayo		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident sustained unexplained bruise while in care
Staff did not properly supervise resident

INVESTIGATION FINDINGS:

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On this day at around 3 pm, Licensing Program Analysts (LPAs) Luisa Fontanilla and Kelly Nguyen arrived unannounced to deliver findings for the above allegations. LPA met with Gina Velayo and explained the purpose of the visit.

During the course of investigation, the Department conducted interviews and record reviews. A review of the records obtained from the facility, Fremont Fire Department and Alameda County Coroner’s Bureau do not suggest that Resident 1 (R1) was a fall risk and needed assistance in ambulating, nor did R1 sustain an injury that would indicate neglect or lack of supervision. The Coroner’s Report indicates R1 passed away due to natural causes, no signs of foul play or trauma. R1’s primary doctor signed the death certificate as natural causes. R1 has a medical history of hypertension and diabetes.

continuation on Lic 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230718143211

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: 04/11/2024

NARRATIVE

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Based on interview conducted with Investigator 1 (I1), I1 states that both the Fremont Fire and Police Departments concluded R1’s death as a result of medical history and the doctor concurred. I1 stated that I1 was not aware of any bruises on R1’s face. I1 stated that many elderly people will have bruising at the time of death but it’s not necessarily an indication of foul play or neglect. The bruise can change rapidly after the time of death and with medical intervention. R1 had 30 minutes of CPR without being revived. I1 stated that alone can affect the appearance of the bruise. Unless there is a large wound or lots of swelling, a bruise would not likely trigger further investigation by the coroner’s office.

A review of R1’s Reassessment dated April 1, 2023 indicates R1 needs reminders to change clothes into clean clothing 2x a day, escorting and/or physical assistance to attend meals only, self manages during the day but requires assistance to/from the bathroom at night and medication assistance.
A review of the facility’s Resident Communication Log dated 7/2 – 7/3, 2023 indicates R1 was checked by S1 at 12:30 am and 2:00 am. The next check was conducted at 5am when S1 found R1 unconscious and unresponsive.

Based on interviews and record reviews conducted, the above allegations are unsubstantiated.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

There is no deficiency noted. A copy of this report was provided to the Velayo.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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