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 visit was triggered by a self-reported incident of an unwitnessed fall by Resident 1 on 2025-10-25 resulting in a lower leg fracture treated on 2025-10-27. The incident was substantiated by the facility's report and medical documentation.

The Licensing Program Analyst reviewed the incident report, interviewed relevant staff, and reviewed Resident 1's care documents. No deficiencies were cited during the visit.

The visit was triggered by a self-reported incident of Resident 1 having an unwitnessed fall on 2025-10-25 resulting in a lower leg fracture treated at a hospital on 2025-10-27. The complaint was investigated and no deficiencies were found.

The Licensing Program Analyst reviewed the incident report, interviewed relevant staff, and reviewed the resident's service plan and medical reports. No deficiencies were cited during the visit.

No deficiencies were cited during the visit. The Licensing Program Analyst reviewed medical and care records related to the incident and will request additional documentation including full medical records and death certificate.

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.

During the visit, relevant medical and care documents were reviewed. No deficiencies were cited during the visit.

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 visit found no deficiencies. The internal brain bleed was due to a hemorrhagic stroke as confirmed by review of the After Visit Summary.

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

The facility was toured and records reviewed with no deficiencies cited. All safety equipment was operational, resident and staff records were complete and up to date, and environmental conditions met regulatory standards.

The visit found no deficiencies. The internal brain bleed was confirmed to be due to a hemorrhagic stroke based on the After Visit Summary.

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 and reviewed the incident.

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 facility was found to be in compliance with no deficiencies cited. The inspection included a tour of the facility, review of resident and staff records, and verification of safety and environmental conditions.

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 alleged that staff charged residents for services not received. The investigation was unannounced and included interviews and document reviews. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The investigation found that residents were not charged for tray services during three COVID outbreaks and that escort and small group activities were provided. There was insufficient evidence to substantiate the allegation, and no deficiencies were cited.

The complaint alleged that the licensee initiated an eviction process in retaliation against a resident. The investigation found no preponderance of evidence to substantiate the allegation, and it was deemed unsubstantiated.

Based on interviews with three staff members and record review, the eviction was due to a higher level of care needed by the resident and not retaliation. There was insufficient evidence to prove the alleged violation occurred, so the allegation was unsubstantiated.

The complaint alleged that the licensee initiated an eviction process in retaliation against a resident. The investigation found no preponderance of evidence to substantiate the allegation, and it was determined to be unsubstantiated.

Based on interviews with three staff members and record review, the eviction was due to a higher level of care needed by the resident and not retaliation. There was insufficient evidence to prove the alleged violation occurred, so the allegation was unsubstantiated.

The complaint involved allegations that staff did not treat residents with dignity and respect, did not include residents' responsible parties in reappraisal processes, and that the facility charged residents for services not agreed upon. The investigation found no sufficient evidence to substantiate these allegations.

The investigation included interviews with staff and residents and review of records. The allegations were found to be unsubstantiated due to lack of preponderance of evidence, with staff and residents reporting respectful care and proper notification of responsible parties.

The complaint alleged illegal eviction. The investigation included interviews with three staff members and review of relevant documents. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The investigation found that although the allegation of illegal eviction may have occurred, there was insufficient evidence to substantiate the claim. The facility followed procedures related to resident care needs and eviction notices when care needs increased beyond the facility's capacity to provide care.

The complaint included allegations that staff did not treat residents with dignity and respect, did not include resident's responsible party in the reappraisal process, and that the facility was charging residents for services not agreed upon. The investigation found these allegations unsubstantiated.

The investigation included interviews with staff and residents and review of records. The allegations were found to be unsubstantiated due to lack of preponderance of evidence. Staff and residents reported respectful care, and documentation confirmed reappraisal and notification of responsible parties. The facility communicated about increased care needs appropriately.

The complaint alleged illegal eviction of a resident. The facility stated that eviction notices are given when a resident's level of care increases beyond what the facility can provide. The investigation included interviews with three staff members and review of relevant documents. The allegation was determined to be unsubstantiated.

The investigation found that although the allegation of illegal eviction may have occurred or be valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur, resulting in an unsubstantiated finding.

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

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

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 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.

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

The complaint alleged that facility staff did not seek medical attention for a resident in a timely manner. The resident was given the wrong medication around 8:00 AM on May 28, 2023, and staff realized the error at 9:24 AM. The resident was assessed and vitals were stable initially, but later changed around 10:15 AM, prompting an immediate 9-1-1 call and hospital transport. The allegation was unsubstantiated due to lack of preponderance of evidence.

The investigation found that a resident was given the wrong medication and there was a delay of approximately 45 minutes before 9-1-1 was called. However, after reviewing interviews, records, and communications, there was insufficient evidence to substantiate the allegation, and it was determined to be unsubstantiated.

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 complaint investigation was unsubstantiated based on interviews with five staff and five residents, and review of documentation. Allegations included lack of supervision causing falls, theft of belongings, confidentiality breaches, discouragement of pendant use, and insufficient staffing leading to early dining room transport. No evidence supported these claims.

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 unrestricted pendant use, and residents denied missing belongings. The allegations were determined to be unsubstantiated.

The complaint alleged that staff charged residents for services not received. The investigation found no preponderance of evidence to prove the alleged violation occurred, and the allegation was unsubstantiated.

Based on interviews with staff and residents' representatives and review of records, there was no evidence that residents were charged for tray services or other services during the COVID-19 outbreak. The allegation was determined to be unsubstantiated.

The inspection found the facility to be in compliance with no deficiencies cited. The facility was well maintained with adequate safety measures, proper staffing, and appropriate supplies. Updated documents were requested for submission by 7/12/2023.

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.

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 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 visit was triggered by a complaint incident report dated 2023-05-18 about a resident ingesting calligraphy ink. The complaint was investigated and found to have no adverse health outcomes.

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 determine if the ink was harmful. No deficiencies were cited during the visit.

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.

No deficiencies were cited during the visit. The facility census was confirmed to be within licensed capacity.

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 the inspection.

The complaint involved an allegation by Resident 2 that Staff 5 hit Resident 1 on 7/2/22. 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 the resident. Staff 5 had no previous complaints and up-to-date training. No deficiencies were cited during the 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.

Resident 1 reported abuse from Staff 5. Facility notified law enforcement and Resident 1's responsible party. Staff 5 was suspended immediately and terminated on 12/28/2021. Facility plans to conduct abuse training for all staff on 1/5/2022.

The investigation revealed 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.