019200761-6-6-2022-15-AS-KHOS-CFDLRV-20220614085947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200761
Report Date: 06/06/2022
Date Signed: 06/06/2022 12:03:54 PM

Substantiated

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
10/19/2020 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20201019103045

FACILITY NAME:	FREMONT HILLS		FACILITY NUMBER:	019200761
ADMINISTRATOR:	NEWMAN, JOAN		FACILITY TYPE:	740
ADDRESS:	35490 MISSION BLVD		TELEPHONE:	(510) 796-4200
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	140	CENSUS:	DATE:	06/06/2022
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Mandeep Kaur, Program Director		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Facility is in disrepair.

INVESTIGATION FINDINGS:

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On 6/6/2022 at 9:50AM, Licensing Program Analysts (LPAs), L. Hall and L. Fici arrived unannounced to deliver complaint findings for the allegation above. LPA met with Mandeep Kaur, Program Director and explained the reason for the visit.

During the course of the investigation LPA A. O’Hollaren interviewed staff and Reporting Party (RP). On the allegation facility is in disrepair RP stated during interview that the curtains were falling off and there were pieces of the blinds missing. During interview with Staff 1 (S1) it was stated that a new maintenance director started on 9/1/2020 and that the previous maintenance assistant was closing work orders that had not been completed. S1 could not verify if the request was completed.

Continued on LIC9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

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

Control Number 15-AS-20201019103045

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: 06/06/2022

NARRATIVE

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Continued from LIC9099.

Based on LPA interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20201019103045

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/06/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/13/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator agreed to review regulation 87303 and submit a self-certification that the regulation has been reviewed and facility will abide by the regulation. Self-certification shall be submitted to CCLD by POC date.
	8 9 10 11 12 13 14	Based on LPAs interview licensee did not comply with the section above in facility being in good repair, which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
10/19/2020 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20201019103045

FACILITY NAME:	FREMONT HILLS		FACILITY NUMBER:	019200761
ADMINISTRATOR:	NEWMAN, JOAN		FACILITY TYPE:	740
ADDRESS:	35490 MISSION BLVD		TELEPHONE:	(510) 796-4200
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	140	CENSUS:	DATE:	06/06/2022
		UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Mandeep Kaur, Program Director		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Staff are not meeting resident's needs.

Resident left in soiled diaper for an extended period of time.

Staff not providing adequate laundry service for resident.

INVESTIGATION FINDINGS:

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On 6/6/2022 at 9:50AM, Licensing Program Analysts (LPAs), L. Hall and L. Fici arrived unannounced to deliver complaint findings for the allegations above. LPA met with Mandeep Kaur, Program Director and explained the reason for the visit.

During the course of the investigation LPA A. O’Hollaren interviewed staff and RP. On the allegation staff are not meeting resident's needs interviews and record reviews indicates Resident 1 (R1) was admitted to hospice services the end of April 2020. The hospice nurse came twice a week. Per the admission agreement and schedules housekeeping services are provided once a week, and additional housekeeping, as needed or request, are available for an additional fee.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20201019103045

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: 06/06/2022

NARRATIVE

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Continued from LIC9099.

On the allegation resident left in soiled diaper for an extended period of time LPA A. O'Hollaren interviewed Staff 2 (S2) which stated staff goal is to change residents every two (2) hours or when soiled. Review of hospice notes did not indicate resident was left in soiled diaper.

On the allegation staff not providing adequate laundry services. LPA A. O'Hollaren interviews and record review indicates laundry services are provided once a week, and additional laundry services, as needed or requested, are available for an additional fee. LPA A O'Hollaren conducted a tele-visit with S1 on 10/23/2020. During tele-visit LPA observed R1's bedroom. The laundry basket was not full , but did have a few clothes inside, the sink area was clean, the smoke detector green light was on, but there were 2 blinds missing.

Although the allegations 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.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5