019200761-7-8-2021-15-AS-KHOS-C5CP8J-20210728110536

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200761
Report Date: 07/08/2021
Date Signed: 07/08/2021 03:38:44 PM

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
06/15/2021 and conducted by Evaluator Allison O'Hollaren

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210615110507

FACILITY NAME:	FREMONT HILLS		FACILITY NUMBER:	019200761
ADMINISTRATOR:	DELOS SANTOS, MICHELLE		FACILITY TYPE:	740
ADDRESS:	35490 MISSION BLVD		TELEPHONE:	(510) 796-4200
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	140	CENSUS: 69	DATE:	07/08/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Michelle Delos Santos		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility does not deliver hot water to residents

INVESTIGATION FINDINGS:

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On 07/08/2021 at approximately 9:30am Licensing Program Analyst (LPA) Allison O'Hollaren arrived unannounced to conduct an initial complaint opening. LPA met with Administrator Michelle Delos Santos and explained the purpose of the visit.

During visit, LPA interviewed Administrator and one staff, reviewed receipts, and communications to residents and responsible parties. During interviews and reviewing records it was revealed that the water heater at the facility did not work from 06/09/2021 until 06/19/2021. During that time the facility offered warm sponge baths from 06/09/2021-06/18/2021, hotel showers for assisted living residents that included

Continued on LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'Hollaren	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

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-20210615110507

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 HILLS	FACILITY NUMBER: 019200761
	VISIT DATE: 07/08/2021

NARRATIVE

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transportation from 06/13/2021-06/15/2021, and a ADA compliant onsite shower trailer from 06/14/2021-06/21/2021. The facility sent notices regarding the water heater to the residents and responsible parties on 06/08/2021, 06/10/2021, 06/13/2021, and 06/22/2021.

This agency has investigated the complaint allegation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or are without reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted with Administrator and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Allison O'Hollaren	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC9099 (FAS) - (06/04)

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