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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200761
Report Date: 01/13/2023
Date Signed: 01/13/2023 12:46:32 PM


Document Has Been Signed on 01/13/2023 12:46 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:FREMONT HILLSFACILITY NUMBER:
019200761
ADMINISTRATOR:BERNADETTE MILOFACILITY TYPE:
740
ADDRESS:35490 MISSION BLVDTELEPHONE:
(510) 796-4200
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:140CENSUS: 68DATE:
01/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:BERNADETTE MILO- Administrator TIME COMPLETED:
01:00 PM
NARRATIVE
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On 1/13/2023, at 12:10PM, Licensing program analysts (LPAs) L. Fici And C. Lin arrived unannounced to conducted a case management about an incident that the LPA was informed about. LPAs met and was greeted by Administrator, BERNADETTE MILO and explained the purpose of the visit.

On 1/11/2023, LPA was informed of an incident at the facility occurred on 12/31/2022 and the administrator failed to submit an Lic624 to CCL. Administrator emailed LPA an Lic624 regarding the incident that occurred on 1/11/2023. LPAs discussed with administrator the regulation on reporting requirements to be submitted to CCL on a timely manner.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Deficiency is being cited due to reporting requirements


Exit interview conducted with administrator, appeal rights given with a copy of this report.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
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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Document Has Been Signed on 01/13/2023 12:46 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
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: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2023
Section Cited

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87211(a)(1) Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...
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Administrator agreed to conduct a in-service training on the regulation Reporting Requirements and to have staff sign the in-service training and to submit to CCL by POC due date.
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This requirement is not met as evidenced by:

Based on interview and record review, the administrator did not comply with the section cited above by not reporting an incident to CCL within 7 days of the occurrence which poses a potential health, safety or personal rights risk to persons in care.
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
LIC809 (FAS) - (06/04)
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