019200848-2-21-2024-15-AS-CFOR-D2NTN6-20240221135214

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200848
Report Date: 02/21/2024
Date Signed: 02/21/2024 01:52:42 PM

Document Has Been Signed on 02/21/2024 01:52 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 FREMON		FACILITY NUMBER:	019200848
ADMINISTRATOR:	KABADI, SANJAY P		FACILITY TYPE:	740
ADDRESS:	2860 COUNTRY DRIVE		TELEPHONE:	(510) 790-1645
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	40	CENSUS: 36	DATE:	02/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	MICHAEL SHARKEY, ADMINISTRATOR		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 2/21/2024 at 9:50am, Licensing Program Analysts (LPAs) Carol Fowler and Tonica Syess-Gibson, arrived unannounced to continue the 1-Year Annual Required inspection visit. LPAs met with Michael Sharkey, Administrator, Sarah Husain Business Office Manager and Imelda Macabayah Health and Wellness Director and explained the purpose of the visit. LPAs toured the facility with Health and Wellness Director including but not limited to apartments, bathrooms, kitchen, common area, med tech room, and outside. LPAs toured apartments #102 and #140. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 112.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non slip shower mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/17/2023. Emergency disaster plan last updated 8/23/2023. First aid kit was observed to be complete. Fire drill was last conducted on 1/10/2024. Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 FREMON	FACILITY NUMBER: 019200848
	VISIT DATE: 02/21/2024

NARRATIVE

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Continued from LIC809.

LPAs reviewed ten (10) resident records and one (1) staff record, which were all found to be incomplete.

LPAs requested the following documents to be submitted to CCLD by 2/29/2024.

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

Deficiencies observed by LPAs during record review:

At 1:00PM LPA observed staff and residents file incomplete.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

LPAs interviewed three (3) residents.

Exit interview conducted. Copy of report, LIC-809 & 809C, LIC-809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to staff.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/21/2024 01:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 FREMON	FACILITY NUMBER: 019200848
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by having incomplete staff files which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/05/2024
	Plan of Correction
1 2 3 4	Administrator agreed to complete staff files and email a sample and check list to CCL by POC.

Type B

Section Cited

CCR

87506(a)

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by having incomplete staff files which poses a potential health and safety rights to persons in care.
	POC Due Date: 03/05/2024
	Plan of Correction
1 2 3 4	Administrator agreed to complete resident file and email a check list and sample file to CCL by POC date.

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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC809 (FAS) - (06/04)

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