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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200761
Report Date: 03/14/2025
Date Signed: 03/14/2025 04:24:43 PM

Document Has Been Signed on 03/14/2025 04:24 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/
DIRECTOR:		VIRAY, BERNADETTE MFACILITY TYPE:
740
ADDRESS:35490 MISSION BLVDTELEPHONE:
(510) 796-4200
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 140TOTAL ENROLLED CHILDREN: 0CENSUS: 96DATE:
03/14/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Judith Gitonga, Director of Health and Wellness TIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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On 03/14/2025, at 2:15 PM Licensing Program Analysts (LPAs), P. Manalo and K. Nguyen arrived unannounced to conduct a case management following up an incident that was reported to CCLD on 02/27/2025 regarding R1 obtaining a wound while in the hospital. LPAs met with Director of Health and Wellness, Judith Gitonga, and explained the reason for the visit.

LPAs reviewed R1's Physician's Report dated 2022, 2023, and 2025, Senior Living Standard Level of Care and Service Plan, Service Plan Report, Watermark Assessment, Elopement Risk Screening, Outside Agency Documentation, Progress Notes, and Discharge Summary.

LPAs interviewed S1 and indicated that they had done an assessment prior to the resident returning back to the facility.

LPAs are requesting to obtain Staff Contact information, Staff Schedule, Previous Service Plan Reports, and other notes pertaining to R1's injury (Caregiver's Notes) by 03/19/2025.

LPAs will return at a later time.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
Yvonne Flores-LariosTELEPHONE: (510) 286-4201
Patricia ManaloTELEPHONE: (916) 432-7785
DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025
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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