Fremont Village.
Fremont Village is Ranked in the bottom 8% on citation severity among California peers with 16 CDSS citations on record; last inspected Apr 2026.
Memory Care RCFE in Fremont with 120 Licensed Beds, reviewed on public record.
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Compared to 93 California facilities with a similar number of beds.
RCFE memory care · 36-month window. Higher percentile = better performance on inspection record. Source: California Dept. of Social Services · Community Care Licensing.
among peers to rank.
Rankings based on 36-month CDSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
FACILITY WATCH · BETA
Fremont Village has 16 citations on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
16 deficiencies on record. Each bar is a month with a citation.
Finding distribution
16 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility.
State requirements with the exact regulation citation, plain-language explanation, and a question to ask on tour. Rules this facility has been cited for appear first.
Plain language
Because a facility markets dementia or Alzheimer's care, state law mandates higher training standards: 12 hours of initial dementia training (6 hours before a staff member works independently with residents, 6 more within the first 4 weeks), 8 hours of annual dementia in-service every year thereafter, and an administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle. Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
Ask on tour
“Can you show me each direct-care staffer's most recent dementia training certificate, and tell me when their next refresher is due?”
Questions to ask before you visit.
A short pre-tour checklist tailored to Fremont Village's record and state requirements.
State records show 3 Type A deficiencies indicating actual harm to residents — what were the specific circumstances of each citation, and what corrective actions were implemented?
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Five complaints have been filed with CDSS during the inspection period — which complaints were substantiated, and what changes resulted from the investigations?
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With 9 Type B deficiencies citing potential for harm across 21 inspections, what systemic changes has Fremont Village made to reduce the frequency of regulatory violations?
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Every inspection visit, verbatim.
15 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2026-04-09Other VisitType B · 2 findings
Plain-language summary
On April 9, 2026, inspectors conducted a follow-up visit after a previous complaint and found window blinds in disrepair in multiple resident rooms in the memory care unit, and observed two residents restrained with seat belts while sitting in wheelchairs—staff gave conflicting explanations, with one saying the belts were only for transportation and another saying they were necessary because the residents were fall risks. The facility was cited for these violations and must submit a plan to correct them.
“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.”
“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.”
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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.
2025-10-03Other VisitNo findings
Plain-language summary
On October 3, 2025, state inspectors conducted a case management visit to verify that the facility received a disciplinary order for a staff member who had worked there through an outside agency and was terminated in February 2023. The inspectors confirmed with the administrator, interviewed staff, and reviewed records to verify that this person was no longer working at the facility. No deficiencies were found.
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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.
2025-09-22Annual Compliance VisitType A · 8 findings
Plain-language summary
On September 19, 2025, inspectors conducted a routine annual inspection and found multiple problems: expired food items in storage; cleaning chemicals and medications left unlocked and accessible to residents; a resident's room with a broken toilet, mattress with holes, and visible filth; broken air conditioning in the dining hall; hot water temperatures below safe levels in some bathrooms; and pre-poured medications stored improperly in a janitor's room. The facility also failed to have current care plans on file for four residents and had a family member living in a resident's room. The facility received citations and was required to submit a plan to correct these deficiencies.
“Based on observations, the licensee did not comply with the section cited above by having items including but not limited to 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 which poses an immediate safety risk to persons in care. POC Due Date: 09/23/2025 Plan of Correction 1 2 3 4 The Administrator agrees to self-cetify the regulation and locked the items. Proof of correction will be sent to CCLD by POC date.”
“Based on observation, the licensee did not comply with the section cited above by having items including but not limited to hydrocortisone cream, Ketoconazole 2% shampoo, prescribed cerave face wash, saline wound cleanser, One Day Vitamin, insulin, etc., in residents' room unlocked and accessible to residents' in care which poses an immediate safety risk to persons in care. POC Due Date: 09/23/2025 Plan of Correction 1 2 3 4 The Administrator agrees to self-certify the regulation and locked the items. Proof of correction will be sent to CCLD by POC date.”
“Based on observation, the licensee did not comply with the section cited above by having items in disrepair such as dresser handle, ac in the memory care unit, air conditioning in the dining hall, dirty showers, resident’s toilet covered in feces, dirty showers. LPAs also observed items such as foul odor, washing machine, portable heaters, broken toilet, old mattress left out which poses a potential health, safety or personal rights risk to persons in care. POC Due Date: 10/06/2025 Plan of Correction 1 2 3 4 The Administrator agrees to ensure the facility is in good repair and sanitary. Proof of correction will be sent to CCLD by POC date.”
“Based on observation, the licensee did not comply with the section cited above by not having the hot water temperature measured within range which poses a potential safety risk to persons in care. POC Due Date: 09/26/2025 Plan of Correction 1 2 3 4 The Administrator agrees to have the water temperature measured within range and send proof of correction to CCLD by POC date.”
“Based on observation, the licensee did not comply with the section cited above by multiple boxes of sugar dated 05/01/2019 and expired in 2021, canned goods and opened pasta not properly labeled. LPAs also observed mineral oil in a Purell Surface Disinfectant Spray bottle which poses a potential health and safety risk to persons in care. POC Due Date: 09/30/2025 Plan of Correction 1 2 3 4 The Administrator agrees to throw out the expired food and self certify the regulation with kitchen staff. Proof of correction will be sent to CCLD by POC date.”
“Based on record review, the licensee did not comply with the section cited above by not having an updated Appraisal Needs and Services Plan (LIC625) for R1, R2, R4, and R7 which poses a potential health and safety risk to persons in care. POC Due Date: 10/06/2025 Plan of Correction 1 2 3 4 The Administrator agrees to submit an updated LIC625 for the residents and ensure all residents have an updated LIC625. Proof of correction will be sent to CCLD by POC date.”
“Based on observation, the licensee did not comply with the section cited above by having a resident's family member reside in the resident's room which poses a potential personal rights risk to persons in care. POC Due Date: 09/30/2025 Plan of Correction 1 2 3 4 The Administrator agrees to come up with a plan for the residents' visitors staying overnight and send proof to CCLD by POC date.”
“Based on observation and interview, the licensee did not comply with the section cited above by medications prepoured to be administered the following day which poses a potential health and safety risk to persons in care. POC Due Date: 10/06/2025 Plan of Correction 1 2 3 4 The Administrator agrees to conduct an in-service on stopping the prepouring for medications and submit to CCLD by POC date.”
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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... 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 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... 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 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.
2025-09-19Other VisitNo findings
Plain-language summary
On September 19, 2025, state inspectors conducted the facility's required annual inspection and met with management to explain the visit. The inspectors confirmed the facility's fire clearance allows for up to 120 residents, including those who are non-ambulatory or bedridden, plus a hospice waiver for 15 residents. The inspection was not completed that day and inspectors plan to return to finish their review.
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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.
2025-08-20Other VisitNo findings
Plain-language summary
During an unannounced case management visit on August 20, 2025, inspectors found that the facility's admission agreement was missing two policies: the visitation policy and the isolation policy. The administrator agreed to submit a plan for how the facility will handle visits, including when residents share rooms, by August 29, 2025.
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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.
2025-08-20Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint alleged that staff prohibited resident visitation. Staff and family members interviewed confirmed that families can visit during designated visiting hours and have access to multiple spaces including a visitation room, courtyard, and residents' rooms, though scheduling visits in advance is requested. No violation was found.
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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.
2025-08-07Other VisitNo findings
Plain-language summary
An inspector visited the facility on August 7, 2025 to investigate a priority complaint and conducted a comprehensive health and safety inspection, checking hot water temperatures, bathrooms, lighting, food storage, medication security, fire safety equipment, and passageways. No violations were found; the facility had adequate lighting, properly secured medications and sharp objects, working smoke and carbon monoxide detectors, a complete first-aid kit, and safe bathroom features including grab bars and non-skid surfaces. The inspector confirmed there was sufficient food on hand and no safety hazards in indoor or outdoor areas.
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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.
2025-06-05Other VisitType B · 2 findings
Plain-language summary
On June 5, 2025, state licensing investigated after the facility self-reported that a resident with dementia exited through a window in another resident's room on June 3rd and was found down the street; the facility had a window alarm system but staff sometimes turned it off to open windows, the alarm status was unknown at the time of the incident, and the inspector found the window in the resident's room had a displaced alarm sensor, broken windowsill, and rust damage. The facility was cited for deficiencies related to these conditions.
“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.”
“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.”
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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.
2024-12-03Other VisitNo findings
Plain-language summary
On December 3, 2024, state inspectors returned to check on a freezer thermostat that was not working properly during an October inspection. The facility had already purchased and installed a new thermostat, and inspectors confirmed it was functioning correctly. No violations were found.
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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.
2024-10-29Annual Compliance VisitType A · 3 findings
Plain-language summary
This was the facility's annual required inspection on October 29, 2024, and inspectors found three deficiencies: a broken freezer thermometer that could not be read, one staff member not properly associated with the facility, and six residents without current care plans documenting their assessed needs and services. The facility otherwise met safety standards, with adequate lighting, working smoke and carbon monoxide detectors, properly stored medications, and grab bars in bathrooms. The facility was required to submit updated documentation and correct these issues by November 6, 2024.
“Based on observation, the licensee did not comply with the section cited above in having a malfunction thermostat in the freezer which poses a potential health and safety risk to persons in care. POC Due Date: 11/05/2024 Plan of Correction 1 2 3 4 Administrator agrees to place a new thermostat for the freezer and send proof to CCLD by the POC date.”
“Based on record review, the licensee did not comply with the section cited above by not having an updated Appraisals Needs and Services Plan for R1 to R6 which poses a potential health and safety risk to persons in care. POC Due Date: 11/12/2024 Plan of Correction 1 2 3 4 Administrator agrees to complete an updated appraisal needs and services plan for R1 to R6 and agrees to update the rest of the community service plan on annual basis. Proof of correction will be sent to CCLD by POC date.”
“Based on record review, the licensee did not comply with the section cited above in having S6 not associated to the facility which poses an immediate health and safety risk to persons in care. POC Due Date: 10/31/2024 Plan of Correction 1 2 3 4 Administrator agrees to associate S6 to Guardian and send proof of correction to CCLD by POC date.”
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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... 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 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.
2024-04-11Other VisitType A · 1 finding
Plain-language summary
This was a case management visit following a complaint about a resident who was found unconscious at 5 a.m. Staff called 911 at 5:21 a.m., and one staff member performed CPR, though there is some uncertainty in staff recollection about the exact sequence of events that morning. The facility was cited for a deficiency related to this incident and must submit a correction plan.
“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.”
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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.
2024-04-11Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint about a resident's death was investigated; fire, police, and the resident's doctor all concluded the death resulted from the resident's medical history rather than facility neglect or misconduct. Staff had checked on the resident at 12:30 a.m. and 2:00 a.m., and found them unresponsive at 5:00 a.m., and the investigator found insufficient evidence to substantiate the complaint. No violations were found.
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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.
2023-11-14Complaint InvestigationUnsubstantiatedNo findings
Plain-language summary
A complaint investigation looked into allegations that staff spoke inappropriately to a resident, did not help with hygiene needs, did not arrange timely dental care, and did not keep a resident's room clean. Based on interviews with staff and residents, review of care records, and facility observations, investigators found no evidence to support these allegations—staff confirmed they assist residents with daily hygiene, rooms and bathrooms are cleaned regularly, and dental care records show the resident has been seen frequently by dental providers since 2021. The complaint was deemed unsubstantiated.
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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.
2023-09-08Other VisitNo findings
Plain-language summary
This was the facility's required annual inspection on September 8, 2023, during which inspectors found no violations. The inspector toured the 70-bedroom facility, reviewed staff and resident records, checked medications, and confirmed that safety features like smoke detectors, fire extinguishers, and emergency supplies were in place and functional.
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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.
2023-07-21Annual Compliance VisitNo findings
Plain-language summary
A health and safety inspection was conducted on July 21, 2023 following a priority complaint, and inspectors found the facility met all requirements: hot water, food storage, refrigeration, medication security, fire safety equipment, and emergency supplies were all in proper working order, and passageways were clear and unobstructed. No violations were cited.
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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.
4 older inspections from 2021 are not shown in the free view.
4 older inspections from 2021 are not shown in the free view.
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