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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200761
Report Date: 09/29/2023
Date Signed: 09/29/2023 06:36:23 PM


Document Has Been Signed on 09/29/2023 06:36 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:FREMONT HILLSFACILITY NUMBER:
019200761
ADMINISTRATOR:VIRAY, BERNADETTE MFACILITY TYPE:
740
ADDRESS:35490 MISSION BLVDTELEPHONE:
(510) 796-4200
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:140CENSUS: 74DATE:
09/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:VIRAY, BERNADETTE M- Administrator (ADM)TIME COMPLETED:
06:45 PM
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On 9/29/2023 starting at 2:50 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Viray, Bernadette, administrator (ADM) and explained the purpose of the visit. The facility’s fire clearance was approved for One Hundred Forty (140) non-ambulatory residents, of which Ten (10) may be bedridden. Upon entry, LPA observed three (3) staff and two (2) residents present during inspection.

Starting at 2:56 PM, LPA toured facility with ADM including but not limited to one hundred nine (109) bedrooms, 109 bathrooms, kitchen, common area and backyard. The facility consists of 109 total bedrooms, which eighty five (85) bedrooms are private, and twelve (12) bedrooms are shared. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 73 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents'. The hot water temperature in residents’ bathroom on the second floor was measured at 119.8 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day supply of perishable foods. Sharps and toxins were locked and inaccessible to residents'.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was observed last serviced on 6/6/2023. First aid kit was observed to be complete.


Continue on Lic809-C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/29/2023
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Continued from Lic809

Starting At 4:03 PM, LPA reviewed 10 of 10 staff records. At 5:14 PM, LPA reviewed 10 of 10 residents' records. At 6:25 PM, LPA reviewed 10 of 10 residents' medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/6/2023:

· LIC 308 Designation of Administrative Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 Pages)
· Liability Insurance





No deficiencies cited during visit.







Exit interview conducted with ADM, and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2