019200761-11-15-2024-15-AS-PMAO-DB2U5S-20241115141712

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200761
Report Date: 11/15/2024
Date Signed: 11/15/2024 02:17:25 PM

Document Has Been Signed on 11/15/2024 02:17 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	FREMONT HILLS		FACILITY NUMBER:	019200761
ADMINISTRATOR/ DIRECTOR:	VIRAY, BERNADETTE M		FACILITY TYPE:	740
ADDRESS:	35490 MISSION BLVD		TELEPHONE:	(510) 796-4200
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY: 140	TOTAL ENROLLED CHILDREN: 0	CENSUS: 88	DATE:	11/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Molly Young, Generations Program Director		TIME VISIT/ INSPECTION COMPLETED:	02:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/15/2024 at 8:30 AM, Licensing Program Analysts (LPAs) P. Manalo and J. Sampair arrived unannounced to conduct the Required Annual inspection. The LPAs met with Generations Program Director, Molly Young, and explained the purpose of the visit. The facility’s fire clearance was approved for one hundred and forty (140) all may be non-ambulatory, of which ten (10) may be bedridden, and ten (10) may be on hospice. The LPAs toured the facility with the Director, including, but not limited to, residents' apartments, bathrooms, multiple activity rooms, kitchen, common area, and courtyard. The LPAs observed that the lighting in all rooms is adequate for the comfort and safety of the residents. The residents' room temperature was maintained at 70 degrees Fahrenheit. The hot water temperature in a sample of residents’ shared bathroom was measured at 109.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of one week supply of nonperishable and 2 days of perishable foods. Centrally stored medications, sharps, and toxic cleaning materials are locked and inaccessible to residents in care. Fire extinguishers were last serviced on 06/06/2024. Emergency Disaster Plan was last reviewed on 11/15/2024. First aid kit was observed to be complete. Fire drill was last conducted on 08/27/2024. At 9:30 AM, LPAs reviewed 6 residents records. At 10:05 AM, LPAs reviewed 5 staff records and 5 of 5 have current first aid training and 5 of 5 associated to the facility. At 12:00 PM, LPAs reviewed a sample of resident’s medications. Continue to LIC809-C...

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FREMONT HILLS	FACILITY NUMBER: 019200761
	VISIT DATE: 11/15/2024

NARRATIVE

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Continued from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 11/22/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate
Inspection Report of Fire Alarm and Carbon Monoxide

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 10:15 AM, LPAs observed S1 and S2 did not have LIC 503 in the files.

At 10:17 AM, LPAs observed S1, S2, and S5 did not have a TB test on file.

At 12:45 PM, LPAs observed that there was no personal rights and nondiscrimination notice information posted.

At 12:50 PM, LPAs observed that the Complaint and Ombudsman poster was not the correct poster size.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Generations Program Director. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Patricia Manalo	TELEPHONE: (916) 432-7785
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2024 02:17 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FREMONT HILLS	FACILITY NUMBER: 019200761
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having a health screening for S1 and S2 on file. Also, S1, S2, and S5 do not have a TB test on file which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/02/2024
	Plan of Correction
1 2 3 4	Generations Program Director agrees to have a health screening completed for S1 and S2. Generations Program Director also agrees to have a TB test completed for S1, S2, and S5. Proof of correction will be sent to CCLD by POC date. Proof of Corrections will be sent to CCLD by POC date.

Section Cited

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in not having the post of personal rights, nondiscrimination notice, and the right size for the complaint and ombudsman poster which poses a potential health and safety risk to persons in care. Proof of Corrections will be sent to CCLD by POC date.
	POC Due Date: 11/22/2024
	Plan of Correction
1 2 3 4	Generations Program Director agrees to post the personal rights, nondiscrimination poster, and to obtain the right size for the complaint and ombudsman poster by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Yvonne Flores-Larios	TELEPHONE: (510) 286-4201
Patricia Manalo	TELEPHONE: (916) 432-7785
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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