Fremont Village

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.

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.

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.

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.

On 7/15//2021 at 1:05PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a case management visit regarding an incident report received on 7/9/2021. LPA met with Executive Director, Gina Velayo and explained the reason for the visit. Incident report dated 7/8/2021 revealed that R1 AWOL'd and facility notified R1's responsible party. R1 was found by On-Lok driver approximately one (1) hour later and escorted to the clinic, Interviews with staff revealed that R1 left the facility during the afternoon bingo activity. S1 stated that facility staff looked for resident inside, outside and in the neighborhood, but unable to find R1. Staff noticed a window in the dining room was open, screen was torn, a chair placed in front of the window, and determined that is where R1 exited the facility. R1 was brought back to the facility from the clinic. S1 was able to provide LPA with physician's report for R1. S1 did not have any other records for R1. LPA requested the following documents: admission agreement, pre-placement assessment, and appraisal needs and services The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalty. Exit interview conducted. A copy of this report and appeal rights provided.

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.

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.

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 .

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.

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.

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.

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.

On 9/8/2023 starting at 1:40 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Gina A. Velayo, Administrator (ADM), and explained the purpose of the visit. Administrators certificate (6004858740) is valid and expires on 11/5/2023. The facility’s fire clearance was approved for one hundred, twenty (120) non-ambulatory residents, which sixty-four may be bedridden and approved for fifteen (15) hospice. Upon entry, LPA observed two (2) staff and four (4) residents present during inspection. Starting at 1:55 PM, LPA toured facility with Licensee including but not limited to seventy (70) bedrooms, 70 bathrooms, kitchen, common area and backyard. The facility consists of 70 total bedrooms which twenty bedrooms are private, and fifty room 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 82 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents'. The hot water temperature in residents’ common area bathroom was measured at 109.8 Degrees Fahrenheit. 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 3/22/2023. First aid kit was observed to be complete. Continue on Lic809-C 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 26 27 28 29 30 31 32 Continued from Lic809 Starting At 2:37 PM, LPA reviewed 10 of 10 staff records. At 3:35 PM, LPA reviewed 10 of 10 residents' records. At 4:34 PM, LPA reviewed a sample of 10 of 10 residents' medication. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 9/15/2023: · 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.

On 7/21/23 at 10:45 AM, Licensing Program Analyst (LPA) L. Fici conducted a Health & Safety inspection as a result of a priority 2 complaint. LPA met with Jojo Ocampo, Business Office Manager (BOM) and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 111.6 degrees F in residents bedroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Refrigerator temperature was observed at 39.3 degrees F and freezer was at 0 degrees F. Resident's medications were kept locked and inaccessible to residents. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector was observed and operational. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 3/22/2023. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

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.

On 09/29/2022, at 1:40 PM, Licensing Program Analyst (LPAs) L. Fici and C. Lin arrived unannounced to conduct Infection Control Inspection. LPAs met with Gina A Velayo, administrator (ADM) and explained the purpose of the visit. During the inspection, LPAs toured facility including but not limited to common areas, hand washing stations, bedrooms, bathrooms, kitchen and courtyard. LPAs observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPAs observed PPE's are sufficient. Food and paper supplies are sufficient. Hand sanitizer is provided at facility entrance. Water temperature is measured at 109.3 degrees F. Fire extinguisher was last serviced on March 23, 2022. LPAs observed facility passages inside and out are free of obstruction. Smoke and carbon monoxide detectors were observed and maintained. Common areas are disinfected 3 times a day. During record review, LPAs observed facility has a copy of Mitigation Plan and emergency disaster plan on file. No deficiencies cited during visit. Exit interview conducted with ADM and a copy of this report provided.

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 2 nd 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.