Inspection Reports for
Aegis Gardens Fremont

The inspection found that Resident 1 had an unwitnessed fall on 12/16/2025, was treated with pain medication, and later sent to the Emergency Room due to a change in condition. The facility had implemented additional safety checks and used a sensor system. No deficiencies were cited during the visit.

The visit was triggered by a self-reported incident concerning a resident sent to the hospital on 12/06/2025 and later diagnosed with a stage 3 pressure ulcer. The complaint was investigated through interviews and document reviews, with no deficiencies found.

The investigation found that the resident had a stage 2 pressure ulcer prior to hospitalization and that home health care had been monitoring the wound since June 2025. No deficiencies were cited during the visit.

The complaint was determined to be unfounded after interviews and review of records, indicating the allegations were false or could not have happened.

The investigation found that the complaint was generated under the wrong facility and all allegations were unfounded, meaning the allegations were false or without reasonable basis.

The complaint alleged that staff obstructed the facility passageway. The allegation was substantiated based on evidence including staff interviews, incident reports, and observations. The Executive Director verified the obstruction occurred on 10/15/2025 and 10/22/2025.

The investigation found that chairs were used to block the side exit door in the memory care unit during activities, which posed a potential safety risk. The allegation was substantiated based on interviews, observations, and document review.

The visit was triggered by a self-reported incident where Resident 1 was hospitalized for a worsening pressure injury on 10/03/2025 and is currently admitted to a skilled nursing facility.

During the visit, documents related to Resident 1's care were reviewed, and no deficiencies were cited. The Licensing Program Analyst will request Resident 1's full medical record and may return later.

No deficiencies were cited during the visit. The Licensing Program Analyst reviewed medical and care records related to Resident 1 and requested additional documentation for further review.

The visit was complaint-related due to a self-reported incident where Resident 1 went AWOL. The incident was substantiated by record review and interviews indicating lack of supervision.

The facility failed to provide adequate supervision, resulting in a resident leaving the facility unsupervised, which posed a potential health and safety risk. The resident was later returned by police, and corrective measures such as use of a Wanderguard Bracelet and safety checks were implemented.

The visit was complaint-related due to a self-reported incident of Resident 1 eloping from the facility. The deficiency was substantiated as the licensee failed to provide adequate supervision.

The licensee did not provide adequate supervision, resulting in Resident 1 leaving the facility unsupervised, posing a potential health and safety risk. The facility has since implemented safety measures including a Wanderguard Bracelet, safety checks, and an AUGi system.

The Licensing Program Analysts toured the facility and reviewed resident and staff records, medications, and safety equipment. No deficiencies were cited during the visit.

The inspection found no deficiencies. The fracture was determined to be due to osteoporosis sequela, and the facility provided relevant medical documentation.

No deficiencies were cited during the visit. Licensing Program Analysts interviewed involved parties but were unable to obtain relevant information from a resident due to dementia. An exit interview was conducted and a copy of the report was provided.

The Licensing Program Analyst toured the facility and reviewed resident and staff records. No deficiencies were cited during the visit, and all safety and operational standards observed were satisfactory.

The visit involved delivery of complaint findings from an amended complaint dated 6/13/2023. No deficiencies were cited during this visit.

No deficiencies were cited during the visit. Licensing Program Analysts met with the Health Services Director and explained the purpose of the visit. An exit interview was conducted and a copy of the report was provided.

The visit was related to complaint findings from an amended complaint dated 06/13/2023. No deficiencies were cited during this visit.

No deficiencies were cited during the visit. Licensing Program Analysts met with the Health Services Director and explained the purpose of the visit. An exit interview was conducted and a copy of the report was provided.

The complaint alleged that staff charged residents for services not received. The investigation included interviews with staff and review of billing statements and service delivery records. The allegation was found to be unsubstantiated.

The investigation found no evidence to substantiate the allegation. Residents were not charged for tray services during three COVID outbreaks, and escort and small group activities were provided as documented. Therefore, the allegation was unsubstantiated and no deficiencies were cited.

The complaint was substantiated based on evidence that staff crushed and administered medication to resident R1 without prior physician approval. The physician later approved the medication crushing after the incident.

The investigation substantiated the allegation that a resident's medication was crushed and administered without a physician's order on July 8, 2023. The physician approved the request to crush the medication on July 12, 2023, after the incident.

No deficiencies were cited during this visit. The Licensing Program Analyst obtained the original report from the Registered Nurse and conducted an exit interview.

The complaint alleged that staff did not dispense medication according to doctor's orders. The allegation was substantiated based on interviews and record review. A staff member was suspended during the investigation. The licensee did not comply with regulations regarding residents' personal rights and medication administration.

The investigation found that a staff member accidentally grabbed the incorrect eye drop bottle and was stopped before administering it to a resident. Additionally, on 6/23/2023, a staff member administered multiple drops instead of one as ordered. These allegations were substantiated based on interviews and record reviews.

No deficiencies were cited during this visit. The Licensing Program Analyst obtained the original report from the Registered Nurse and conducted an exit interview with the General Manager.

No deficiencies were cited during this visit. The Licensing Program Analyst met with the Registered Nurse and obtained the original report.

The complaint investigation was unsubstantiated based on interviews with five staff and five residents, and review of documents including incident reports and service plans. Allegations included multiple falls due to lack of supervision, staff stealing belongings, confidentiality breaches, discouragement of pendant use, and insufficient staffing causing early dining room transport. No violations were proven.

After interviews with staff and residents and review of relevant documents, there was no preponderance of evidence to substantiate the allegations. Staff confirmed safety checks and pendant use were unrestricted, and residents denied missing belongings. The allegation of early dining room transport was explained as a preference by some residents. The allegations were determined to be unsubstantiated.

The visit was complaint-related, opened as a 10-day initial complaint visit (15-AS-20230711115733). The complaint involved resident R1 who was hospitalized and returned with a restricted health condition without an exemption. The deficiency was substantiated.

The licensing analyst observed that the facility did not request or have an exemption on file for R1's restricted health condition, which is a violation of California Code of Regulation, Title 22. The deficiency was cited and may result in civil penalties if not corrected.

The inspection found the facility to be in compliance with no deficiencies cited. The facility was observed to be well maintained with adequate safety measures, proper staffing and resident records, and appropriate supplies and equipment.

No deficiencies were cited during this visit. The Licensing Program Analyst obtained the original report from the Registered Nurse and conducted an exit interview.

Investigation of complaint 15-AS-20230608092900 regarding resident falls on 10/16/2022, 12/20/2022, and 5/9/2023. The complaint was substantiated by the finding that incident reports were not submitted timely.

The facility failed to submit incident reports to the licensing agency in a timely manner for a resident who sustained falls on three separate occasions. This noncompliance with Title 22 Reporting Requirements was discussed with facility staff and cited as a deficiency.

The investigation found that the resident ingested calligraphy ink but had no concerning health issues upon return to the facility. Poison control was notified but could not confirm harm from the ink. No deficiencies were cited during the visit.

The complaint was substantiated. Staff member S2 mistakenly administered 11 types of oral medications from another resident to R1 on 5/28/2023, causing a medication overdose. Incident reports, progress notes, and staff statements confirmed the error. The resident was hospitalized and returned the next day.

The investigation substantiated that on 5/28/2023, a staff member mistakenly gave a resident 11 types of oral medications intended for another resident, resulting in a medication overdose requiring hospital admission. The facility failed to comply with personnel and medication administration regulations, posing immediate health and safety risks.

The facility was confirmed to be operating under its licensed capacity with a census of 73 residents out of 85 licensed beds. No deficiencies were cited during this visit.

The facility was found to have adequate infection control measures including proper PPE use, sufficient food supply, universal screening, and routine disinfection. No deficiencies were cited during this inspection.

The complaint involved an allegation by Resident 2 that Staff 5 hit Resident 1. The facility notified the Ombudsman but not the police. The internal investigation and interviews found no evidence to substantiate the allegation.

The investigation found no evidence that Staff 5 hit Resident 1. Staff 5 had no previous complaints and up-to-date training. No deficiencies were cited during the visit.

The complaint involved alleged abuse of Resident 1 by Staff 5. The facility notified law enforcement and the resident's responsible party. Staff 5 was suspended and terminated following the investigation.

The investigation found that Resident 1 reported abuse by Staff 5. Staff 5 was suspended immediately and terminated after the investigation. No deficiencies were cited during the visit.

The applicant and administrator successfully completed Component II, demonstrating understanding of facility operation, staff qualifications, program policies, and application document requirements. No deficiencies or violations were noted in the report.

The applicant and administrator successfully completed COMP II, confirming their understanding of Title 22 regulations including facility operation, staff qualifications, program policies, and application document requirements. The applicant was advised to submit required documentation to CAB.