019200761-9-22-2023-15-AS-KHOS-CVZSSL-20230925140806

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200761
Report Date: 09/22/2023
Date Signed: 09/22/2023 04:46:20 PM

Unsubstantiated

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
04/19/2023 and conducted by Evaluator Liridon Fici

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230419121808

FACILITY NAME:	FREMONT HILLS		FACILITY NUMBER:	019200761
ADMINISTRATOR:	VIRAY, BERNADETTE M		FACILITY TYPE:	740
ADDRESS:	35490 MISSION BLVD		TELEPHONE:	(510) 796-4200
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	140	CENSUS: 74	DATE:	09/22/2023
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	VIRAY, BERNADETTE M		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Resident was left on the floor for an extended period of time.
Staff do not ensure adequate supervision is provided to residents in care.
Staff do not ensure resident receives bathing assistance.
Staff do not respond to resident’s signal system in a timely manner.
Staff do not follow residents’ dietary restrictions.

INVESTIGATION FINDINGS:

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On 9/22/2023 at 10:40 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a complaint investigation visit and to deliver findings on the above allegations. LPA met with VIRAY, BERNADETTE M, administrator (ADM) and explained the purpose of today’s visit.

During the course of the investigation, LPA interviewed five (5) staff and obtained the following documents: Residents and staff roster, needs and service plan, progress note (February and March 2023), call log, and physician reports.

During today’s visit, LPA interviewed seven (7) residents at 12:40PM, and two (2) staff at 2:31PM.

Continue on Lic9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230419121808

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: 09/22/2023

NARRATIVE

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It was alleged that; Resident was left on the floor for an extended period of time and staff do not ensure adequate supervision is provided to residents in care. Based on interviews conducted, all staff stated that staff check on residents every hour to 2 hours to make sure residents are doing well. Staff stated that, depending on residents’ care plan, staff will check on residents more often than others to ensure that residents are doing fine. During the AM, and PM shifts, staff stated that there are 3 to 4 care staff plus one med tech, and during the NOC shift, there are 2 staff in the memory unit and 2 staff in the assisted living unit plus ones med tech. All residents stated that staff check on residents daily and often to ensure residents are doing well.

It was alleged that; Staff do not ensure resident receives bathing assistance and staff do not respond to resident’s signal system in a timely manner. Based on interviews and record review conducted, staff stated that ADLs are performed on a daily basis and showers are given to all residents, usually in the mornings or as needed per resident’s needs. LPA reviewed point of care (POC) logs which indicated that staff are preforming R1’s ADLs which are documented. Staff stated when a resident calls for assistance, it alerts staff on their radio, so staff knows which room to go to. LPA reviewed facility call log, which indicated that staff are responding to R1’s calls in a timely manner when R1 calls for assistance. Residents stated that ADLs are preformed on a daily basis by staff or residents are able to care for their own ADLs without staff assisting them. Residents have also stated that when a resident calls for staff, staff are there to assist residents within 5 minutes to 10 minutes.

It was alleged that; Staff do not follow resident’s dietary restrictions. Based on interviews conducted, all staff stated that if a resident has a dietary restriction, a log is created that informs staff what each resident can or cannot have. If a resident need purred food, mechanical soft foods, no certain meats, or low salt foods, etc, facility will accommodate for those dietary needs. Dietary logs are located in the memory care unit, in the kitchen and dinning area for staff to see.

Based on Interviews record review conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with ADM, and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC9099 (FAS) - (06/04)

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