Inspection Reports for Aegis Living Fremont

The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements at Aegis Assisted Living of Fremont.

The facility was generally compliant with safety and operational standards, including adequate lighting, proper water temperatures, and functioning smoke and carbon monoxide detectors. However, a deficiency was cited for storing emergency food in the same closet as antibacterial liquid soap and water supply, posing a health and safety risk.

This case management visit was conducted as a follow-up on the facility's compliance plan resulting from the Non-Compliance Conference held on March 25, 2025.

During the visit, an inspection of the Memory Care unit was conducted and resident files were reviewed. Discussions were held regarding the facility's fall prevention plan. No deficiencies were cited.

An unannounced Case Management visit was conducted regarding a self-reported incident involving a resident's unwitnessed fall resulting in a femur fracture.

The Licensing Program Analysts reviewed relevant documents and interviewed staff. No deficiencies were cited during the visit.

The visit was triggered by a self-reported incident on 07/17/2025 involving Resident 1 who sustained a femur fracture after an unwitnessed fall. The complaint was investigated and no deficiencies were found.

The visit was an unannounced Case Management inspection regarding a self-reported incident involving a resident's unwitnessed fall resulting in an avulsion fracture.

The Licensing Program Analysts reviewed relevant medical and service documents and interviewed facility staff. The facility and resident's family are in communication regarding care. No deficiencies were cited during the visit.

Unannounced case management visit conducted by Licensing Program Analysts to evaluate compliance with licensing requirements.

Two deficiencies were observed: Tide Pod left unlocked in the washing machine room in Memory Care 2, and sanitation wipes left unlocked in Memory Care 1, posing immediate safety risks to residents.

An unannounced Case Management visit was conducted regarding a self-reported medication error that occurred on 2025-07-20, involving administration of a discontinued PRN medication to a resident.

The facility failed to comply with medication administration requirements by giving Resident 1 a discontinued PRN medication, posing a potential health and safety risk. The resident was monitored and showed no side effects. A Type B deficiency was cited.

The visit was triggered by a self-reported medication error incident involving Resident 1 receiving a discontinued PRN medication on 2025-07-20. The incident was self-reported by the Health Services Director on 2025-07-24. The resident was monitored and showed no adverse effects.

An unannounced Case Management visit was conducted regarding a self-reported incident involving a resident's unwitnessed fall and wrist fracture.

The Licensing Program Analyst reviewed the resident's service plan and medical reports and found no deficiencies during the visit.

An unannounced Case Management visit was conducted regarding a self-reported incident involving a resident's unwitnessed fall and subsequent treatment for a closed hip fracture.

The Licensing Program Analyst reviewed medical and service records, spoke with the resident, and found no deficiencies during the visit.

The inspection visit was an unannounced Case Management visit regarding a self-reported restraint abuse incident that occurred on 2025-06-23.

The investigation found that the resident did not sustain injuries during the incident. The private caregiver involved was sent home and barred from the facility. No deficiencies were cited during the visit.

The visit was triggered by a self-reported restraint abuse incident on 2025-06-23 by the Health Services Director, Leslie Ibo. The complaint was investigated and found unsubstantiated as no injuries occurred.

An unannounced Case Management visit was conducted regarding a self-reported missed medication incident that occurred on 2025-06-12 involving Resident 1's insulin dose.

The facility failed to administer the morning insulin dose to Resident 1 due to the safety on the needle remaining intact, resulting in a missed medication. The resident was monitored and showed no side effects. A Type B deficiency was cited for failure to comply with care and supervision requirements.

The visit was complaint-related due to a self-reported missed medication incident. The complaint was substantiated as evidenced by the deficiency cited.

The visit was a case management legal non-compliance follow-up conducted to assess the facility's compliance plan following a Non-Compliance Conference held on March 25, 2025.

During the visit, an inspection of the Memory Care unit revealed laundry baskets blocking two residents' doors, which were promptly removed. A technical violation was issued during the visit.

An unannounced Case Management visit was conducted regarding a self-reported incident involving multiple falls by a resident.

The Health Services Director self-reported multiple falls by Resident 1 on three consecutive days. The facility updated the resident's Service Plan and moved the resident to the Memory Care Unit, after which no further falls occurred. No deficiencies were cited during the visit.

An unannounced Case Management visit was conducted regarding a self-reported incident involving a resident's unwitnessed fall and subsequent fracture.

The review of the resident's medical documents indicated the fracture was sustained prior to moving in. No deficiencies were cited during the visit.

An unannounced Case Management visit was conducted regarding a self-reported incident involving a resident's unwitnessed fall and subsequent injury.

The visit found no deficiencies; the After Visit Summary indicated no evidence of spine fracture and the injury was attributed to age indeterminate factors.

The visit was an unannounced case management inspection conducted in response to a priority 1 complaint received on 2024-04-09 regarding resident supervision and safety concerns.

The Licensing Program Analyst found no deficiencies during the visit. The Executive Director had conducted staff retraining on proper care and supervision of residents with dementia following the complaint.

The complaint alleged that a male memory care resident entered another resident's bedroom and remained there unattended for over an hour, and that memory care residents were left unsupervised in the common room. The complaint was investigated and no deficiencies were cited.

Unannounced complaint investigation visit conducted due to allegation that staff did not provide adequate supervision resulting in a resident sustaining multiple fractures while in care.

The allegation was substantiated based on interviews, observations, and record reviews showing the resident sustained multiple falls and serious fractures due to inadequate supervision. An immediate civil penalty of $500 was assessed for failure to provide adequate care and supervision.

Allegation of neglect/lack of supervision resulting in resident sustaining multiple fractures was substantiated. Resident had 5 documented falls since admission in 2022, with serious fractures to femur and pelvis. Staff failed to provide adequate supervision despite multiple fall prevention methods and expressed concerns.

An unannounced Case Management visit was conducted regarding a self-reported incident by the Health Services Director on 2025-01-13.

No deficiencies were cited during the visit. Licensing Program Analysts reviewed multiple resident and facility documents and requested a copy of the Death Certificate to be sent by 2025-02-15.

An unannounced Case Management visit was conducted regarding a self-reported abuse incident that occurred on 2024-11-29.

The investigation included interviews with residents and staff, review of relevant documents, and confirmed that the staff member involved was terminated and removed from the facility roster. No deficiencies were cited during the visit.

The visit was triggered by a self-reported abuse incident involving a staff member pulling a resident's leg. The staff member was terminated on 2024-12-05 and removed from the facility roster.

The visit was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.

The inspection found no deficiencies. The facility was toured, records reviewed, and safety equipment checked, all meeting required standards. Updated copies of certain administrative documents were requested for submission by 11/04/2024.

The visit was an unannounced case management inspection conducted in response to an Unusual Incident Report submitted by the facility regarding a missing bottle of narcotic medication following a resident's death.

The investigation found that an unused bottle of narcotic medication was missing after a resident passed away. Despite searching medication carts and cabinets, the medication was not found. The incident was reported to the police, and staff received in-service training on narcotic handling and documentation. No deficiencies were cited.

The visit was an unannounced case management inspection conducted in response to an Unusual Incident Report submitted by the facility regarding a resident's sudden death.

The resident experienced a sudden death while receiving morning ADL care, CPR was administered for about 45 minutes, and the coroner was not required to visit. No deficiencies were cited during the visit.

The visit was an unannounced case management inspection to deliver an amended LIC9099D page from a prior visit conducted on 09/24/2024.

No deficiencies were cited during the visit. An exit interview was conducted and a copy of the report was provided to the facility representative.

The inspection was an unannounced complaint investigation visit conducted in response to an allegation that staff locked residents in their rooms.

The investigation substantiated the allegation that a staff member placed laundry baskets in front of residents' rooms to prevent them from wandering, effectively locking them in. The staff member was separated from the facility for this misconduct.

The complaint was substantiated based on interviews, document review, and photographic evidence. The staff member admitted to locking residents in their rooms and was separated from the facility on 04/22/2024 for misconduct.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-07-03 regarding allegations that a resident sustained an injury while in care and that staff did not report the incident to the Community Care Licensing (CCL).

The investigation substantiated that the resident sustained a traumatic subarachnoid hemorrhage consistent with an accidental fall, and the facility failed to report the serious injury to the licensing agency. Additional allegations about staff communication and seeking medical attention were unsubstantiated. Two Type B deficiencies were cited related to failure to report the injury and failure to observe the resident closely enough to detect the fall.

The complaint investigation was substantiated for the allegation that a resident sustained an injury while in care and that staff did not report the incident to CCL. Other allegations regarding staff communication and seeking medical attention were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not seek medical attention for a resident, did not report the incident to the licensing agency, and did not communicate with the resident's responsible party.

The investigation substantiated the allegations that staff failed to seek medical attention for a resident who had two unwitnessed falls, failed to report the incidents to the licensing agency, and failed to notify the resident's family. Deficiencies were cited related to these failures.

The complaint was substantiated. Allegations included staff not seeking medical attention for a resident after two unwitnessed falls, not reporting the incident to the licensing agency, and not communicating with the resident's responsible party. The investigation included interviews, record reviews, and evidence collection. The findings confirmed the allegations.

An unannounced Health and Safety check was conducted due to the department receiving a priority 1 complaint.

During the health and safety check, residents appeared comfortable and safe with no imminent health or safety concerns observed. No deficiencies were cited during the inspection.

The visit was triggered by a priority 1 complaint; no deficiencies were found and residents were safe.

The visit was an unannounced complaint investigation conducted in response to allegations that staff abused residents while in care and violated residents' personal rights.

Based on interviews with residents and staff, and review of records, there was no preponderance of evidence to substantiate the allegations of abuse or violation of personal rights. The allegations were determined to be unsubstantiated.

The complaint investigation was triggered by allegations of staff abuse and violation of residents' personal rights. After interviews and record review, the allegations were found to be unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that the licensee did not follow proper eviction procedures for a resident and that facility staff did not properly supervise a resident resulting in elopement.

The investigation substantiated the allegation that the licensee failed to follow proper eviction procedures by not providing a proper eviction notice to a resident, posing a potential health and safety risk. The allegation regarding improper supervision resulting in elopement was unsubstantiated due to insufficient evidence.

The complaint investigation was initiated based on allegations that the licensee did not follow proper eviction procedures and that facility staff failed to properly supervise a resident resulting in elopement. The eviction procedure allegation was substantiated, while the supervision allegation was unsubstantiated.

The visit was an unannounced 1-Year Annual Required Inspection conducted to evaluate compliance with licensing requirements and facility conditions.

The inspection found the facility to be in compliance with no deficiencies cited. The facility was observed to have adequate safety measures, proper environmental conditions, and appropriate documentation was requested for submission.

The visit was an unannounced case management visit to deliver an amended report originally dated 7/19/2023.

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

An unannounced complaint investigation was conducted in response to an allegation of illegal eviction received on 07/14/2023.

The investigation found that the complaint was unfounded as the alleged resident did not reside at the facility, and the allegation was false or without reasonable basis.

Complaint alleging illegal eviction was investigated and found to be unfounded.

An unannounced complaint investigation visit was conducted in response to an allegation that a resident was hospitalized due to neglect.

Based on interviews and record review, although the allegation may have happened or be valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation was unsubstantiated.

The complaint alleged that a resident was hospitalized due to neglect. The investigation included interviews with residents and staff, and review of relevant documents. Staff described protocols for monitoring residents' health and actions taken when residents show signs of decline. The resident was hospitalized on 1/16/2023 and returned on 2/3/2023. The allegation was found unsubstantiated.

The inspection was conducted as a result of a priority 1 complaint to perform a Health & Safety inspection at the facility.

The Licensing Program Analyst toured the facility and found no deficiencies. All safety measures including hot water temperature, food supplies, medication storage, smoke detectors, carbon monoxide detector, first-aid kit, and fire extinguisher were in compliance.

The visit was triggered by a priority 1 complaint. No deficiencies were cited during the visit.

The visit was conducted for case management regarding an incident that the Licensing Program Analyst was informed about and confirmed during the visit.

The Licensing Program Analyst confirmed the incident occurred and discussed reporting requirements with the administrator. No deficiencies were cited during the visit.

The visit was an unannounced complaint investigation conducted in response to allegations that staff did not report resident's change in condition to responsible party, did not follow resident's physician's orders, and did not assist resident with grooming.

The investigation found that the resident's family was notified of the foot infection, physician's orders were followed for wound care, and grooming activities were performed as required. However, there was insufficient evidence to substantiate the allegations, and the complaint was determined to be unsubstantiated.

The complaint investigation was unsubstantiated based on record reviews and interviews. Allegations included failure to report resident condition changes, failure to follow physician orders, and failure to assist with grooming. Documentation and interviews supported compliance with care requirements.

The visit was an unannounced complaint investigation conducted in response to allegations received on 09/16/2022 regarding staff handling residents roughly, delayed assistance, failure to seek timely medical attention, retaining residents needing higher care, and failure to report incidents to representatives.

The investigation found that staff handled residents according to facility procedures, responded to assistance requests timely, sought medical attention appropriately, provided ongoing care for residents needing higher care, and reported incidents to representatives. However, there was insufficient evidence to substantiate the allegations, resulting in an unsubstantiated finding.

The complaint investigation was unsubstantiated. Allegations included rough handling causing injury, delayed response to assistance requests, failure to seek timely medical attention, retaining residents needing higher care, and failure to report incidents to representatives. Interviews, record reviews, and documentation supported that proper care and reporting occurred.

Unannounced infection control inspection conducted as a required 1-year visit to assess compliance with infection control standards.

The inspection found the facility well-maintained with adequate infection control measures, including signage, PPE availability, hand sanitizer, and proper water temperature. No deficiencies were cited during the visit.

The inspection was an unannounced complaint investigation visit conducted to address allegations received on 2022-02-17 regarding inadequate staff training and other concerns at Aegis Assisted Living of Fremont.

The investigation substantiated that facility staff were not adequately trained, specifically noting an incident where night shift staff did not know the location of the medication key. Other allegations regarding insufficient staffing and failure to update residents' responsible parties were found unsubstantiated.

The complaint investigation was substantiated for inadequate staff training. Other allegations about insufficient staffing and failure to provide updates to residents' responsible parties were unsubstantiated.

The visit was an unannounced case management visit conducted regarding an incident report received on 12/28/2021 involving alleged abuse of a resident by a staff member.

The investigation revealed that Staff 5 was the caregiver involved in the incident with Resident 1. Staff 5 was suspended immediately and terminated after the investigation. The facility planned to conduct abuse training for all staff on 1/5/2022. No deficiencies were cited during the visit.

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

The visit was a Case Management phone call regarding a death report due to a shelter in place order directed by the Governor.

The report detailed the circumstances of a resident's fall resulting in a head injury and subsequent death due to a punctured lung from a broken rib. No deficiencies were cited during this visit.