019200848-5-8-2026-15-AS-BFOG-DVUVUD-20260710164433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200848
Report Date: 05/08/2026
Date Signed: 05/08/2026 03:21:35 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
01/22/2026 and conducted by Evaluator Patricia Manalo

COMPLAINT CONTROL NUMBER: 15-AS-20260122121901

FACILITY NAME:	FREMONT RTRMT COM-HAPPY LVNG BY COGIR/COGIR FREMON		FACILITY NUMBER:	019200848
ADMINISTRATOR:	HUSAIN, SARAH		FACILITY TYPE:	740
ADDRESS:	2860 COUNTRY DRIVE		TELEPHONE:	(510) 790-1645
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	40	CENSUS: 40	DATE:	05/08/2026
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Nikka Pascua, Resident Care Coordinator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff are not allowing LTCO into the facility at residents request
Facility is not providing adequate care due to insufficient staffing

INVESTIGATION FINDINGS:

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On 05/08/2026 at 8:55 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct more investigatations and deliver the findings on the above allegations. LPA met with Resident Care Coordinator, Nikka Pauscua and explained the purpose of the visit. Executive Director, Samuel Ogden, gave verbal authorization for Pascua to sign the report.

During the course of investigation, LPA interviewed Executive Director, Assistant Executive Director, 8 residents, 11 staff members, and witnesses. LPA obtained and reviewed documents including but not limited to Resident Roster, Staff Schedule, Staff Roster, Digital Visitor Log, physician report, and resident care plan.

Continue to LIC9099-C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

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-20260122121901

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 RTRMT COM-HAPPY LVNG BY COGIR/COGIR FREMON	FACILITY NUMBER: 019200848
	VISIT DATE: 05/08/2026

NARRATIVE

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Allegation: Staff are not allowing LTCO into the facility at residents request

It was alleged that Staff are not allowing LTCO into the facility at residents request. Interview with S1 and S2 revealed that guests are to show a form of Identification Card to verify who they are when visiting the facility. Once verified and checked into the facility’s kiosk, the guest can enter. Interview with S1 and S2 indicated that Ombudsman representative, Witness 1 (W1), did not properly introduce themselves and their identification card did not clearly show that they are from the Ombudsman. S1 stated that their identification card shows their picture and the logo, “Empowered Aging” without their name included. S1 and S2 stated that front desk staff are trained to not provide anything confidential to guests and that includes the resident roster without verifying that they are authorized to obtain the roster. S1 also added that due to potential scammers, the front desk is trained to be cautious of guests entering and asking for confidential information. A review of the kiosk sign in sheet, the W1 signed in as a Pharmacist under the Ombudsman Services and interview with S1, S2, and W1 verified that W1 was able to conduct their visit that day and obtain the resident roster after verification.

Based on the investigation, which included staff interviews and review of available documentation, the allegation that staff are not allowing LTCO into the facility at residents request is unsubstantiated. Although the concern was reported, there is insufficient evidence to confirm the allegation. Therefore, the allegation is deemed unsubstantiated at this time.

Allegation: Facility is not providing adequate care due to insufficient staffing

It was alleged that Facility is not providing adequate care due to insufficient staffing. On 03/11/2026 and 05/08/2026, LPA interviewed with 7 residents of which 5 of 7 residents reported that there are times when residents would have to wait for assistance for staff to help. However, interviews with S2, S4, S6, S7, and S8 stated that even though there are less staff for the day, staff members will provide care to the residents as soon as possible. On 03/11/2026, R3 stated that R3 needs assistance with showers, dressing, and medication and R3 stated that R3 gets the care R3 needs.

Continue to LIC9099-C...

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20260122121901

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 RTRMT COM-HAPPY LVNG BY COGIR/COGIR FREMON	FACILITY NUMBER: 019200848
	VISIT DATE: 05/08/2026

NARRATIVE

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Continued from LIC9099-C...

On 03/11/2026, R4 stated that the staff members can get busy, but they are overall good to R4 and R5 when available. On 05/08/2026, R1 and R2 stated that there are some staff members that provide better care than others, but R2 will usually get the help they need. On 05/08/2026, R6 stated that the staff assist residents with their personal care needs and the staff members do provide the care R6 needs.

Based on the investigation, which included staff and resident interviews, the allegation that facility is not providing adequate care due to insufficient staffing is unsubstantiated. Although the concern was reported, there is insufficient evidence to confirm the allegation. Statements obtained during the investigation were inconsistent, and no corroborating evidence was found to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time.

No deficiencies cited.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

LIC9099 (FAS) - (06/04)

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