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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200761
Report Date: 11/12/2021
Date Signed: 11/12/2021 12:50:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:FREMONT HILLSFACILITY NUMBER:
019200761
ADMINISTRATOR:DELOS SANTOS, MICHELLEFACILITY TYPE:
740
ADDRESS:35490 MISSION BLVDTELEPHONE:
(510) 796-4200
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:140CENSUS: 70DATE:
11/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Bernadetter Viray, Sales DirectorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Bernadette Viray, Sales Director. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.

LPA conducted a walk-through of the facility with Sales Director and observed COVID-19 precaution postings. A screening station was observed at front entrance of facility for visitors and staff. LPA was screened for COVID-19 symptoms. Visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Staff follow indoor visitation requirement of verifying COVID-19 vaccination or a negative COVID test within 72 hours for visitors. The facility has designated visitation areas, provides virtual visits and phone calls for family to stay in contact with residents. Staff and resident's temperatures are taken once a day and LPA observed documentation. Staff clean and disinfect the facility three times daily. Sales Director stated high touched surface areas are disinfected after each use.

Staff have documented completion on the following training: infection prevention, symptoms, transmission and PPE use. The facility has a supply of PPE including gloves, face shields/goggles, N-95 respirators, surgical masks and disposable gowns. N-95 respirator Fit testing (Cal/OSHA requirement) has been completed, Sales Director stated the facility would send proof of documentation to CCL.

The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services (CDSS), Community Care Licensing (CCL).

Report continued on LIC809-C...
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: FREMONT HILLS
FACILITY NUMBER: 019200761
VISIT DATE: 11/12/2021
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During inspection, LPA did not observe carbon monoxide detector(s) in the common areas or resident bedrooms. An advisory report LIC9102 was given to facility regarding carbon monoxide detectors.

LPA requested the following updated documents to be submitted to CCLD Oakland Regional Office by 11/22/2021:
· LIC500 – Personnel Report
· LIC 9020 – Register of Facility Residents
· LIC308 – Designation of Administrative Responsibility
· LIC610E – Emergency Disaster Plan
· Administrator Certificate
· Proof of Liability Insurance

· Documents needed to update facility Administrator, to be submitted to CCLD Oakland Regional Office by 12/06/2021:
    · LIC 200 (fully completed & signed by Licensee)
    · LIC 308 Designation of Facility Responsibility (signed by Licensee)
    · Administrator’s Resume or LIC 501 Personnel Record
    · Administrator’s Qualifications & Duties
    · LIC 500 Personnel Report (indicating days & working hours for new Administrator)
    · LIC 503 Health Screening Report – Facility Personnel
    · TB Test – Showing “Negative” Results
    · Administrator’s Certificate
    · First Aid Certification
    · Fingerprint Association to Facility
    · LIC 610E Emergency Disaster Plan for Residential Care Facilities For Elderly
    · Board of Resolution (designating person as administrator)

Facility to notify the CCLD Oakland Regional Office if more time is needed to submit the forms.

Exit interview conducted with Sales Director whose signature on this document confirms receipt.
No deficiencies cited during this inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
LIC809 (FAS) - (06/04)
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