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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200848
Report Date: 12/09/2022
Date Signed: 12/09/2022 01:46:52 PM


Document Has Been Signed on 12/09/2022 01:46 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 RTRMT COM-HAPPY LVNG BY COGIR/COGIR FREMONFACILITY NUMBER:
019200848
ADMINISTRATOR:KABADI, SANJAY PFACILITY TYPE:
740
ADDRESS:2860 COUNTRY DRIVETELEPHONE:
(510) 790-1645
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:40CENSUS: 26DATE:
12/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Joyce Welch-AdministratorTIME COMPLETED:
02:00 PM
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On 12/9/2022, at 10:45AM, Licensing Program Analysts (LPAs) L. Fici and J. Clancy-Czuleger arrived unannounced to conduct a case management visit for a death that occurred on 10/20/2022. LPAs was greeted by Joyce Welch, Administrator (ADM) and Marrissa Okolo, LVN and explained the purpose of visit.

LPAs received a death report that was submitted to CCL on 10/21/2022. LPAs requested the following documents, admission agreement, hospice plan and notes, hospice orders, incident report of fall, residents MAR log, physicians report, and SNF discharge paperwork. LPAs interviewed ADM and LVN regarding the death. Resident had a fall on 10/2/2022, and was admitted to the hospital. On 10/10/2022, resident was placed in skilled nursing facility (SNF) and was discharged back into Cogir of Fremont on 10/14/2022. Resident passed on 10/20/2022. Hospice death report lists cause of death to pre-existing condition.

During record review, LPAs observed medication was being given by hospice and the facility correctly and followed physicians orders for medication administration.

No deficiencies cite at this time.


Exit interview conducted with ADM and LVN, and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
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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