Fremont Village

Allegation investigated: Personal Rights - Lack of care and supervision resulted in resident sustaining a fracture. Personal Rights - Resident was inappropriately restrained while in care. Personal Rights - Staff did not notify responsible party of incident.

On 04/09/2026 at 9:20 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to continue the investigation on the above allegations and deliver findings for the complaint. LPA met with Administrator, Gina Velayo and explained the purpose of the visit. During the course of the investigation, the Department obtained and reviewed the following documents including but not limited to Resident Roster, Staff Roster, Staff Schedule, Admission Agreement, Identification and Emergency Information, Physician’s Report, Preplacement Appraisal, Appraisal Needs and Services Plan, Physician’s Fax Reports, After Visit Summary, Unusual Incident Reports, Facility Visitor Logs, Email Correspondence, Power of Attorney Documentation, Immunization Record, On Lok PACE Level of Care Assessment Tool, On Lok PACE Care Plan, Physician Orders for Life-Sustaining Treatment (POLST), On Lok Fall Incident Report, Facility’s Behavior Log, Communication Log Memory Care Unit, Resident Notes, Resident Communication Log, SOC341, Fall Incident Report Fax Cover Sheet, and photos of the resident’s injury. Continue to LIC9099-C... Unsubstantiated ... Continued from LIC9099... The Department conducted interviews with facility residents, staff, and witnesses. On 04/09/2026, LPA P. Manalo conducted additional interviews with staff, residents, and witnesses and obtained the following documents included but not limited to an updated staff roster, resident roster, and Personnel Report (LIC500). Allegation: Lack of care and supervision resulted in resident sustaining a fracture. It was alleged that lack of care and supervision resulted in resident sustaining a fracture. A review of facility’s resident notes dated 05/10/2024 showed that S1 found R1 sitting on the floor holding their head due to an unwitnessed fall during S1’s last rounds. A review of On Lok Fall Incident Report dated 05/10/2024 revealed that S1 immediately called 911 and R1 was transported to the hospital. Interview conducted by the Department revealed that R1 was not a fall risk per W1. Interview with S1 revealed that R1 was able to walk on their own and would hardly use their assistive device when walking around the facility. S1 stated that when S1 was conducting their last rounds on 05/10/2024, S1 found R1 on the floor. S1 proceeded to call 911 and R1 was taken to the hospital. 3 of 3 staff members all stated that R1 was able to walk on their own independently. The Department obtained and reviewed an intake assessment dated 4/18/24 indicating that R1 was not a fall risk and could ambulate and transfer independently. The physician report dated 4/18/24 did not indicate a mobility concern nor that assistance was needed for this issue. The Department further found that there were no other falls preceding the incident of 5/10/24. No other corroborating evidence was obtained to support the allegation. Based on the investigation, which included interviews and record reviews, the allegation that lack of care and supervision resulted in resident sustaining a fracture is unsubstantiated. Although the concern was reported, there is insufficient evidence to confirm the allegations. Records reviewed were consistent with interviews, and no corroborating evidence was obtained to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time. Continue to LIC9099-C... ... Continued from LIC9099-C... Allegation: Resident was inappropriately restrained while in care. It was alleged that resident was inappropriately restrained while in care. Per email from W1, it seemed like there were signs of restraint and bruises from the fall. On 12/08/2025, the Department received an SOC341 to further describe that W1 thinks that R1 was abused and R1’s legs were tied up. On 04/09/2026, LPA P. Manalo interviewed 9 staff members that all indicated that they have not observed or witnessed any residents restrained while in care. Interview with W5 verified that they come to the facility on monthly basis to check on their residents that are part of the Onlok Pace Program and have not observed any staff restraining residents. 5 of 12 residents interviewed stated that staff do not tie them up. LPA attempted to interview 7 of 12 residents and could not obtain information. LPA interviewed additional witnesses in which 2 of 2 witnesses revealed that they have not witnessed any staff restraining residents or seen the residents tied up inappropriately. Based on the investigation, which included staff interviews and review of available documentation, the allegation that resident was inappropriately restrained while in care 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. Allegation: Staff did not notify responsible party of incident. It was alleged that staff did not notify responsible party of incident. W1’s email indicated that the facility did not notify them of the fall. However, a review of the physician’s fax report from the facility indicated that the facility called 911, notified the On Lok Pace Program, and informed W2 of the incident. A review of the facility’s communication log dated 05/10/2024 revealed that an unknown staff member spoke with W2 via text message that R1 sustained an arm fracture and will be staying in the hospital per W2. Continue to LIC9099-C... ... Continued from LIC9099-C... In addition, S1 reported the incident using On Lok Pace’s Incident Report document dated 05/10/2024 that included that W2 and W4 were notified. Interview conducted by the Department revealed that W1 received a call from the facility that informed W1 of R1’s fall and that R1 was heading to the hospital. On 04/09/2026, LPA P. Manalo spoke with W3 that confirmed W4 spoke with S1 on May 10, 2024, of R1’s fall. Per W3, it was documented on the Onlok Pace system that W4 was notified of R1’s incident on that day. W2 also confirmed that W2 was notified of R1’s fall and that R1 was on the way to the hospital. In addition, interview with 5 of 5 staff members stated that if they observe any incidents, they will notify the Medication Technician (Medtech) on shift of the incident and the Medtech will be the ones to notify the appropriate parties. Interviews with 3 of 3 staff members all confirmed that whenever there are incidents, the facility will notify the family and/ or responsible party, Onlok Providers, and resident’s physician. Based on the investigation, which included staff interviews and review of available documentation, the allegation that staff did not notify responsible party of incident 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. There is no deficiency noted. Exit interview was conducted with Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 15-AS-20250806080132

Type of visit: Case Management - Deficiencies

On 04/09/2026 at 2:30PM Licensing Program Analyst (LPA) P.Manalo conducted a case management as a result of observations during complaint visit 15-AS-20250806080132. LPA met with Administrator, Gina Velayo, and explained the purpose of the visit. While conducting the complaint investigation, LPA observed the following: Starting at 9:56 AM, LPA observed window blinds in disrepair in multiple residents' room in the memory care unit. At 10:00 AM, LPA observed 2 residents with a seat belt while sitting down on their wheelchair. Interview with S1 stated that these residents are part of the Onlok Pace Program and they use the seat belts during transportation and not for daily use. However, interview with S2 stated that these residents are fall risk and without the seat belt, the residents will slide down. Deficiencies is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, a copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a) · Plan of correction due date: Apr 24, 2026

87608(a) ...the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. This requirement is not met as evidenced by: Based on observations and interview, the licensee did not comply with the section cited above by having a seatbelt as postural support for residents in wheelchairs without an exception request which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: By POC date, the Administrator will send an exception request for the all the residents with seatbelt to CCLD for review.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(c) · Plan of correction due date: Apr 24, 2026

87303(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having window blinds in disrepair in multiple residents’ room which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: By POC date, the Administrator agrees to repair the window blinds. In addition, the Administrator will come up with a plan if they will continue to use window blinds or find an alternative for the window covering.

Type of visit: Case Management - Other

On 10/03/2025 at 12:25 PM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct a Case Management visit. LPAs met with Administrator (ADM), Gina Velayo and explained the purpose of the visit. During today's visit, LPAs confirmed with the Administrator, Gina Velayo, regarding the Default Decision and Order for Staff 1 (S1) and if the order has been received. ADM gave verbal confirmation that the Default Decision and Order document has been received by the facility. LPAs spoke with Witness 1 (W1) from Healthcare Services Group Incorporated that verified that S1 was from an outside agency and was terminated on 02/12/2023. LPAs also interviewed five other staff and all verified that S1 has not been or has worked with them at the facility. Record review of Guardian Roster shows that S1 is no longer associated with the facility. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 3, 2025

Type of visit: Case Management - Annual Continuation

On 09/22/2025 at 9:10 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct 1-Year Annual-Continuation Required inspection. LPA met with Administrator, Gina Velayo and explained the purpose of the visit. On 09/19/2025, LPAs toured the facility inside and out including but not limited to 10 residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 74 degrees F. The hot water temperature in a sample of residents’ shared bathrooms were measured at 109.8, 94.4, 89.8, 90, and 93.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats and non-skid shower pan. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 03/07/2025. Emergency Disaster Plan was last posted on 01/20/2025. First aid kit was observed to be complete. Fire drill was last conducted on 05/04/2025. On 09/19/2025 at 10:28 PM, LPA reviewed 7 residents records. At 11:20 AM, LPAs reviewed 6 staff records. 6 of 6 staff have current first aid training and are associated with the facility. At 3:04 PM, LPAs reviewed 3 samples of residents’ medications. Continue to LIC809-C... Continue from LIC809... THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: On 09/19/2025 at 3:23 PM, LPAs observed multiple boxes of sugar dated 05/01/2019 and expired in 2021. LPAs observed canned goods and opened pasta not properly labeled. LPAs observed mineral oil in a Purell Surface Disinfectant Spray bottle. On 09/19/2025, starting at 9:20 AM, LPAs observed broken toilet, mattress, holes in memory care resident's room, broken dresser handle, resident's toilet covered in feces, dirty shower, air condition, washing machine, portable heaters in the library area on second floor, etc. LPAs observed odor in resident's room and the air conditioning broken in the dining hall. On 09/19/2025 at 1:00 PM, LPAs observed the hot water temperature measured between 89.8 degrees F and 94.4 degrees Fahrenheit. On 09/19/2025 starting at 2:41 PM, LPAs observed disinfectant spray, acetone nail polish remover, Arm & Hammer Odor Blaster, laundry detergent, Lysol spray, etc., in multiple areas at the facility unlocked and accessible to residents' in care. On 09/19/2025 starting at 2:41 PM, LPAs observed hydrocortisone cream, Ketoconazole 2% shampoo, prescribed cerave face wash, saline wound cleanser, One day Vitamin, etc., in residents' room unlocked and accessible to residents' in care. On 09/19/2025 at 3:45 PM, LPAs observed pre-poured medication in the janitor's room. Interview with Assistant Administrator revealed that medications was pre-poured for the next day. On 09/19/2025 at 3:47 PM, LPAs observed resident's family member residing in the resident's room Continue to LIC809-C... Continue from LIC809-C... On 09/22/2025 at 11:30 AM, LPAs observed that that R1, R2, R4, and R7 does not have an updated LIC625 Appraisal Needs and Services Plan. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 22, 2025

The state marks this report as 12 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 09/19/2025 at 9:20 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Assistant Administrator, Kareen Galliguez, and explained the purpose of the visit. Galliguez phoned the Administrator (ADM) Gina Velayo to inform the purpose of the visit and got consent that staff can sign the report. The facility’s fire clearance was approved for capacity of 120 residents all may be non-ambulatory, 64 may be bedridden, and a hospice waiver of 15 residents. Due to time, LPAs will return at another date to complete the annual inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 19, 2025

Allegation investigated: Staff prohibit resident visitation

On 08/20/2025 at 12:05 PM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct a complaint investigation and deliver findings on the above allegation. LPA met with Administrator, Gina Velayo, and explained the purpose of the visit. During the course of investigation, LPA interviewed the Administrator (ADM), eight (8) staff members, three (3) witnesses, and family member (FM1). LPA reviewed and obtained documents including but not limited to residents’ Admission Agreement, Resident Information Sheet, Identification and Emergency Information, Resident Roster, Staff Roster, Facility’s Memory Care Visitation Policy, and Facility’s Isolation Policy dated 04/09/2024. Continue to LIC9099-C... Unsubstantiated Continue from LIC9099... It was alleged that staff prohibit resident visitation. Interview with all the staff and ADM indicated that residents’ families can schedule an appointment to reserve a private room for visitation ahead of time, but family members are able to visit any time during visiting hours. It was also indicated that family members can utilize the visitation room, the courtyard, the dining room in the assisted living area, or the resident’s room if they have a private room or if the resident’s roommate was not there. Interview with Witness 1 (W1) and Witness 2 (W2) stated that they have no issues when it comes to visiting residents at the facility. Interview with Witness 3 (W3) and Family Member 1 (FM1) confirmed that they needed to call ahead and arrange a visit, but they were able to visit Resident 1 (R1) in the visitation room. Based on interviews and observations conducted, the above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. There is no deficiency noted. Exit interview was conducted with Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 15-AS-20250814161635

Type of visit: Case Management - Other

On 08/20/2025 at 4:00 PM, Licensing Program Analyst (LPA) P.Manalo arrived unannounced to conduct a case management visit. LPA met with Administrator, Gina Velayo, and explained the purpose of the visit. While LPA was at the facility for another visit, LPA observed during record review that the facility's admission agreement does not include the facility's visitation policy and facility's isolation policy. LPA and Administrator discussed the regulation on personal rights regarding visits and creating a plan visitations when resident's have roommates. Administrator agrees to send LPA an update on what the facility's plan will be regarding visitation policy by 08/29/2025. A technical advisory was issued on this date. Exit interview was conducted with Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 20, 2025

Type of visit: Case Management - Health Checks

On 08/07/2025 at 1:00 PM, Licensing Program Analyst (LPA) P. Manalo conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Administrator Gina Velayo and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and courtyard area. Hot water temperature was measured at 113.1, 109.3, 108.2, 107.1, and 105.6 degrees Fahrenheit residents’ bathroom. Residents’ bathrooms are equipped with grab bars and non-skid shower pans. LPA observed lighting in all rooms is adequate for the comfort and safety of the residents. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were observed in operating condition. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 03/07/2025. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during the visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 7, 2025

Type of visit: Case Management - Incident

On 06/05/2025 at 12:35 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident that occured on 06/03/2025. Administrator self-reported the incident on 06/04/2025. LPA met with Administrator (ADM), Gina Velayo, and explained the purpose of the visit. LPA received an incident report from the facility that indicated Resident 1 (R1) went AWOL by exiting through a window in another resident's room. The facility was doing a headcount after dinner and when they noticed R1 was gone. R1 was found down the street and was escorted by staff to come back to the facility. During the visit, LPA reviewed R1's Physician Report dated 03/09/2023 that indicated that R1 has a diagnosis of Dementia and is not able to leave the facility unassisted. LPA toured the facility and observed the window auditory device where R1 left from was functioning loud and clear. However, based on interview conducted, ADM stated that she does not know whether the alarm was on at that time because staff would sometimes turn it off to open the windows when assisting residents. LPA also observed in R1's room the auditory signal was displaced on the window, the windowsill was broken, and rust on the closet panel. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(d) · Plan of correction due date: Jun 19, 2025

87705(d) Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates... This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above by not having the auditory signal on at the time R1 AWOL from the facility which posed a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: The Administrator agrees to conduct a mandatory in-service training on elopement and wandering behaviors. Proof of correction will be sent to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Jun 19, 2025

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having auditory signal device displaced, R1's windowsill broken, and rust on the closet panel.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: The Administrator will repair the auditory signal device, the windowsill, and have the rust on the closet panel cleaned. Proof of correction will be sent to CCLD by POC date.

Type of visit: Case Management - Incident

On 12/03/2024 at 1:00 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 11/11/2024. LPAs met with Administrator, Gina Velayo, and explained the reason for the visit. LPAs reviewed R1's Physician's Report, Appraisal Needs and Service Plan, and Discharge Summary. LPAs requests for an updated Physician's Report due to resident's new health condition. LPAs will send the requested documents to CCLD by 12/13/2024: Updated Physician's Report and current Physician's Report Discharge Summary Care Notes Appraisal Needs and Services Plan Documentation's of POA November Staff Schedule Staff Contacts No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 3, 2024

Type of visit: POC

On 12/03/2024 at 12:15 PM, Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen conducted an unannounced POC visit regarding the deficiency issued on 10/29/2024. LPAs met with Administrator, Gina Velayo and explained the purpose of the visit. During the annual visit on 10/29/2024, the freezer thermostat was not functioning properly. On 11/02/2024, Administrator sent proof of purchase of thermostat via email to LPA. On 11/08/2024, Administrator sent proof of the thermostat installed via email to LPA. LPA wanted to confirm if the thermostat is functioning properly while at the facility for another visit on this date. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 3, 2024

Type of visit: Required - 1 Year

On 10/29/2024 at 9:00 AM, Licensing Program Analysts (LPAs) P. Manalo and J. Clancy-Czuleger arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator, Gina Velayo, and explained the purpose of the visit. The facility’s fire clearance was approved for one hundred, twenty (120) non-ambulatory residents, which sixty-four (64) may be bedridden and approved for fifteen (15) hospice. LPAs toured the facility with Administrator, Gina Velayo, including but not limited to residents' apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 102.8 and 106.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher all around the facility was last serviced on 03/15/2024 and kitchen fire extinguisher last serviced on 03/15/2024. Emergency Disaster Plan was last posted on 01/15/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 10/04/2024. At 11:15 AM, LPAs reviewed 6 staff records and 5 of 6 are associated to the facility. At 11:45 AM, LPAs reviewed 6 residents records. Continue to LIC809-C... Continue from LIC809... Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/06/2024: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 11:00 AM, LPAs were unable to get accurate read due to malfunctioning thermometer in the freezer. At 11:35 AM, LPAs observed S6 was not associated to the facility. At 12:45 AM, LPAs observed that R1 to R6 did not have a updated and current Appraisal / Needs and Services Plan. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 29, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPAs) Manalo and Clancy-Czuleger arrived unannounced to conduct a case management visit in response to the Unusual Incident Report (UIR) submitted by the facility. LPAs met with Administrator, Gina Velayo, and explained the purpose of the visit. On 10/03/2024, R1 was sent to the hospital for an open wound on coccyx area. When discussing with Administrator, the wound got to this degree because R1 was not accepting care from facility staff. R1 was sent to Skilled Nursing Facility until wound healed and R1 was then readmitted to the facility. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 29, 2024

Allegation investigated: Resident sustained unexplained bruise while in care Staff did not properly supervise resident

On this day at around 3 pm, Licensing Program Analysts (LPAs) Luisa Fontanilla and Kelly Nguyen arrived unannounced to deliver findings for the above allegations. LPA met with Gina Velayo and explained the purpose of the visit. During the course of investigation, the Department conducted interviews and record reviews. A review of the records obtained from the facility, Fremont Fire Department and Alameda County Coroner’s Bureau do not suggest that Resident 1 (R1) was a fall risk and needed assistance in ambulating, nor did R1 sustain an injury that would indicate neglect or lack of supervision. The Coroner’s Report indicates R1 passed away due to natural causes, no signs of foul play or trauma. R1’s primary doctor signed the death certificate as natural causes. R1 has a medical history of hypertension and diabetes. continuation on Lic 9099C Unsubstantiated Based on interview conducted with Investigator 1 (I1), I1 states that both the Fremont Fire and Police Departments concluded R1’s death as a result of medical history and the doctor concurred. I1 stated that I1 was not aware of any bruises on R1’s face. I1 stated that many elderly people will have bruising at the time of death but it’s not necessarily an indication of foul play or neglect. The bruise can change rapidly after the time of death and with medical intervention. R1 had 30 minutes of CPR without being revived. I1 stated that alone can affect the appearance of the bruise. Unless there is a large wound or lots of swelling, a bruise would not likely trigger further investigation by the coroner’s office. A review of R1’s Reassessment dated April 1, 2023 indicates R1 needs reminders to change clothes into clean clothing 2x a day, escorting and/or physical assistance to attend meals only, self manages during the day but requires assistance to/from the bathroom at night and medication assistance. A review of the facility’s Resident Communication Log dated 7/2 – 7/3, 2023 indicates R1 was checked by S1 at 12:30 am and 2:00 am. The next check was conducted at 5am when S1 found R1 unconscious and unresponsive. Based on interviews and record reviews conducted, the above allegations are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. There is no deficiency noted. A copy of this report was provided to the Velayo.the state’s words, verbatim · CDSS document, Apr 11, 2024 · control 15-AS-20230718143211

Type of visit: Case Management - Other

On this day at around 3:30pm, Licensing Program Analysts (LPAs) Luisa Fontanilla and Kelly Nguyen arrived unannounced to conduct a case management visit and met with Gina Velayo. LPA explained to Velayo the purpose of the visit. During the course of investigation of complaint # 15-AS-20230718143211, the Department conducted interviews and reviewed records. Based on interviews conducted, S1 found R1 unconscious at 5 am and called S2 immediately. LPA interviewed S2 who states that S2 responded and went to R1’s room which is on the 2nd floor of the building using the elevator. Once S2 was in R1’s room and saw R1, S2 went downstairs to check R1’s file if R1 has Do Not Resuscitate (DNR). When asked by LPA if S2 performed CPR to R1, S2 does not recall because the incident happened so fast and he “blacked out” but remembered calling S3, another Medication Technician on shift. S1 and S2 both state S3 performed CPR on R1. S2 placed the 911 call recorded at 5:21 am. Deficiency is cited per Title 22 California Code of Regulations. Failure to correct the cited deficiency on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.the state’s words, verbatim · CDSS document, Apr 11, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Apr 17, 2024

87465(g) Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Based on interviews and record reviews conducted, 1) S2 failed to perform CPR for R1 immediately 2) the facility failed to call 911 immediately for R1. R1 was found unresponsive at 5am, 911 call was placed at 5:21 am.the state’s words, verbatim · CDSS document, Apr 11, 2024

Plan of correction: The Administrator will conduct inservice for all staff on the facility's emergency procedures and submit proof of training to CCL by POC date.

Allegation investigated: Staff spoke inappropriately to resident in care. Staff did not assist resident with hygiene needs. Staff did not seek dental care for resident in a timely manner. Staff not ensuring resident's room is clean.

On 11/14/2023, at 1:45 PM, 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 Gina A, Velayo- Administrator (ADM) and explained the purpose of today’s visit. During the course of the investigation, LPA interviewed six (6) residents, and seven (7) staff members. LPA requested and obtained the following documents: Staff roster with contact information, Physicians reports, residents care plan log (October 2020, June 2023, July 2023), dental care plan, admission agreement, progress notes for (October 2020, June 2023). Continue on Lic9099-C... Unsubstantiated Continue from Lic9099 It was alleged that, staff spoke inappropriately to resident in care, and staff did not assist resident with hygiene needs. Based on interviews and record review conducted, all 7 staff stated that activities of Daily Living (ADLs) are being done for residents in the morning, and in the afternoon. LPA reviewed residents care plan log and housekeeping log which indicated that staff are cleaning the residents’ room including the bathrooms to make sure it is clean and sanitized for residents use. LPA confirmed with residents’ during interview that staff do come in to clean their rooms and bathrooms to make sure its clean. It was alleged that; staff did not seek dental care for resident in a timely manner. Based on interviews and record review conducted, staff stated to LPA that On Lok will schedule dental appointments for some residents’. Staff will also contact On Lok to schedule dental appointments as well for residents’ to be seen for dental care. During interview with residents’, residents stated that staff will contact On Lok to schedule dental appointments for residents to be seen and sometimes the family of the residents will schedule dental appointments for residents. LPA reviewed R1’s dental records, which indicated that R1 has been seen frequently by the dental providers since 2021 and continues to be seen by dental providers. It was alleged that, staff not ensuring resident's room is clean. Based on interviews and observation conducted, all staff stated that residents rooms are clean in the morning and afternoon, or as needed. R1- R6 stated staff clean residents’ rooms. On November 14, 2023, LPA observed that the residents bathrooms are kept clean and sanitary for the use of the residents. Based on Interviews record review 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 allegations are UNSUBSTANTIATED. Exit interview conducted with ADM, and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 14, 2023 · control 15-AS-20230628110054