019200761-11-14-2023-15-AS-KHOS-CY2RZV-20231129122833

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200761
Report Date: 11/14/2023
Date Signed: 11/14/2023 01:25:43 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
08/09/2023 and conducted by Evaluator Liridon Fici

COMPLAINT CONTROL NUMBER: 15-AS-20230809111810

FACILITY NAME:	FREMONT HILLS		FACILITY NUMBER:	019200761
ADMINISTRATOR:	VIRAY, BERNADETTE M		FACILITY TYPE:	740
ADDRESS:	35490 MISSION BLVD		TELEPHONE:	(510) 796-4200
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	140	CENSUS: 82	DATE:	11/14/2023
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Molly Young- Memory Care Director (MCD)		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Staff do not ensure that residents’ hygiene needs are being met while in care.
Staff do not ensure that residents’ clothing needs are being met while in care.
Staff do not provide assistance to residents in a timely manner.
Staff do not ensure that resident is provided with clean bedding while in care.
Facility is odiferous.
Facility is unsanitary.

INVESTIGATION FINDINGS:

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On 11/14/2023, at 11:50 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a subsequent complaint investigation visit and to deliver findings on the above allegations. LPA met with Molly Young- Memory Care Director (MCD) and explained the purpose of today’s visit.

During the course of the investigation, LPA interviewed three (3) staff members and four (4) residents. LPA requested and obtained the following documents: Physicians reports, needs and service plans, housekeeping log, Point of care logs (POC) for July 2023 and August 2023, and Response care logs (July 2023 and August 2023) for a sample of 10 of 10 residents.

Contnue on Lic9099-C...
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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023

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-20230809111810

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 HILLS	FACILITY NUMBER: 019200761
	VISIT DATE: 11/14/2023

NARRATIVE

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It was alleged that; Staff do not ensure that resident's hygiene needs are being met while in care and Staff do not ensure that resident's clothing needs are being met while in care. Based on interviews and record review, residents’ activities of Daily living (ADLs) are being cared for and staff are meeting all residents care needs in the morning by care givers. S1 stated that residents’ are on an ADL schedule which indicates that each residents’ ADLs are preformed twice or 3 times a week; some residents’ can request ADLs to be performed if needed. LPA reviewed the facilities point of care logs, which indicates that the residents’ ADLs are being met by care staff. All 3 staff stated ADLs are preformed every day to residents. All 4 residents’ stated that staff care for residents’ ADLs every day and residents’ do not have a problem with their needs being met. Some residents’ are independent and can preform their own ADLs as well.

It was alleged that; Staff do not provide assistance to residents in a timely manner and Staff do not ensure that resident is provided with clean bedding while in care. Based on interviews with staff and residents, all 3 staff stated that when a resident calls for assistance, staff will go to the resident’s room to see what assistance the resident needs, and staff will assist resident with their care needs. Staff stated it takes about 5 minutes or less to response to a residents call after a resident pushes their call button or little longer if a staff is assisting other residents. All 4 residents stated that staff come to their room after the call button is pressed, and sometimes it takes little longer but staff do come to their room shortly after. All 4 residents also mentioned that staff clean their rooms and makes sure all bed sheets are clean and new for the resident to use.

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SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230809111810

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 HILLS	FACILITY NUMBER: 019200761
	VISIT DATE: 11/14/2023

NARRATIVE

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It was alleged that, the facility is odiferous, and the facility is unsanitary. Based on observation and interviews, LPA observed that the facility is clean and sanitary. LPA did not observe the facility to be dirty and is kept clean and smells good. LPA toured the facility, and entered resident’s rooms and observed that the rooms of the facility are kept clean, sanitary and did not have any smell. Staff stated to LPA that care staff makes sure that the facility and the resident’s rooms are kept clean and do not have an odor to them.

Based on Interviews and observation conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with MCD, and a copy of this report provided.

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SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023

LIC9099 (FAS) - (06/04)

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