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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200848
Report Date: 11/15/2024
Date Signed: 11/15/2024 06:13:15 PM

Document Has Been Signed on 11/15/2024 06:13 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/
DIRECTOR:		KABADI, SANJAY PFACILITY TYPE:
740
ADDRESS:2860 COUNTRY DRIVETELEPHONE:
(510) 790-1645
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 40CENSUS: 41DATE:
11/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:00 PM
MET WITH:Michael Sharkey, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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On 11/15/2024 at 5:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Executive Director, Michael Sharkey.

While LPA was at the facility for another visit, LPA observed the following deficiency:

At around 3:00PM, LPA was given the resident roster and was informed that facility had 41 residents. After reviewing facility file, LPA observed that facility's fire clearance capacity is 40 residents. Facility is over capacity.

Civil penalty of $500 is being assessed.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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 11/15/2024 06:13 PM - It Cannot Be Edited


Created By: Grace Luk On 11/15/2024 at 05:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: FREMONT RTRMT COM-HAPPY LVNG BY COGIR/COGIR FREMON
FACILITY NUMBER: 019200848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/18/2024
Section Cited
CCR
87204(a)

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Limitations - Capacity and Ambulatory Status. A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons...
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Executive Director has agreed to create a plan to address the over capacity issue and submit the written plan to CCLD by POC date.
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This requirement is not met as evidence by: Based on observation and record review, licensee did not comply with the section cited above by having over capacity in number of residents which poses an immediate health and safety risk to the persons in care.
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Civil penalty of $500 is being assessed.

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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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