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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200761
Report Date: 12/13/2024
Date Signed: 12/13/2024 05:38:25 PM

Substantiated


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
12/03/2024 and conducted by Evaluator James Sampair
COMPLAINT CONTROL NUMBER: 15-AS-20241203124531
FACILITY NAME:FREMONT HILLSFACILITY NUMBER:
019200761
ADMINISTRATOR:VIRAY, BERNADETTE MFACILITY TYPE:
740
ADDRESS:35490 MISSION BLVDTELEPHONE:
(510) 796-4200
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:140CENSUS: 99DATE:
12/13/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Interim Executive Director Vivian Villegas and Vibrant Life Director Jessica DoerrTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff do not ensure resident has privacy in their room.
INVESTIGATION FINDINGS:
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On 12/13/2024 at 10:30 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this initial 10-day complaint investigation concerning allegations above. LPA met with Interim Executive Director (IED) Vivian Villegas and informed her of the allegations.

The complaint alleges staff do not ensure resident has privacy in their room.
The LPA interviewed Witness W1, Residents R2 and R3, Staff Members S1 and S2, and Vibrant Life Director Jessica Doerr. The data collected confirms the allegation that staff members are not ensuring resident privacy.

Continued on LIC 9099-C . . .
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
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
12/03/2024 and conducted by Evaluator James Sampair
COMPLAINT CONTROL NUMBER: 15-AS-20241203124531

FACILITY NAME:FREMONT HILLSFACILITY NUMBER:
019200761
ADMINISTRATOR:VIRAY, BERNADETTE MFACILITY TYPE:
740
ADDRESS:35490 MISSION BLVDTELEPHONE:
(510) 796-4200
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:140CENSUS: 97DATE:
12/13/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Interim Executive Director Vivian VillegasTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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9
Staff do not ensure that resident is receiving assistance with their dental care.
Staff are unable to communicate with resident due to a language barrier.
Staff do not ensure resident's personal belongings are safeguarded.
INVESTIGATION FINDINGS:
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On 12/13/2024 at 10:30 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct this initial 10-day complaint investigation concerning allegations above. LPA met with Interim Executive Director (IED) Vivian Villegas and informed her of the allegations.

The complaint alleges staff do not ensure that resident is receiving assistance with their dental care.
The LPA interviewed Witness W1 who stated that dental care for Resident R1 had been completed. The data collected does not confirm the allegation.

The complaint alleges staff are unable to communicate with resident due to a language barrier.
The LPA interviewed Witness W1 who stated that Resident R1 had not complained of communication interferring with their care. The data collected does not confirm the allegation.

Continued on LIC 9099-C . . .
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20241203124531
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 HILLS
FACILITY NUMBER: 019200761
VISIT DATE: 12/13/2024
NARRATIVE
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....Continued from LIC 9099

The complaint alleges staff do not ensure resident's personal belongings are safeguarded.
The LPA interviewed Witness W1 who stated that Resident R1's belongings had not been stolen or removed from their room. They had been placed in a different location in their room than R1 was used to them being located. The data collected does not confirm the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20241203124531
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 HILLS
FACILITY NUMBER: 019200761
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2024
Section Cited
CCR
87468.2(a)(1)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) … residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, … and meetings of resident and family groups.
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On or before the due date, the Administrator shall inform CCLD that the entire staff have been retrained on on resident personal privacy.
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This requirement is not met as evidenced by:

Resident statement, "They may knock, but then do not wait long enough for me to tell them to come in. It doesn't respect my privacy when they do that."
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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: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20241203124531
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 HILLS
FACILITY NUMBER: 019200761
VISIT DATE: 12/13/2024
NARRATIVE
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...Continued from LIC 9099

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099-D.

Exit interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5