Inspection Reports for Atherton Court Alzheimer’s Residence
38035 Martha Avenue, Fremont, CA 94536, CA, 94536
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating the facility generally meets regulatory standards. The most recent report from July 16, 2025, had no deficiencies despite a noted strong urine odor in a resident’s room, and the resident was found clean and well cared for. The facility had two serious deficiencies in its June 25, 2025 annual inspection involving an unlocked medication cart and improper storage of germicidal wipes near food, both posing immediate health and safety risks, along with a documentation issue; these were addressed with plans of correction. Earlier complaint investigations, including those related to medication errors, staffing, and resident care, were all unsubstantiated. The facility’s record shows mostly compliance with isolated safety and medication management issues that were corrected, with no fines or enforcement actions listed in the available reports.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Census: 24
Capacity: 40
Deficiencies: 0
Jul 16, 2025
Visit Reason
The visit was an unannounced case management inspection conducted due to a self-report of a resident's hygiene needs not being met and lack of documentation of the resident's change in condition.
Findings
During the visit, the Licensing Program Analyst observed a strong smell of urine in the resident's room but found the resident in clean clothing and linens. Interviews and document reviews were conducted, and no deficiencies were cited.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffery Jackson | Health and Wellness Director | Met with Licensing Program Analyst during the inspection and interviewed regarding resident care. |
Inspection Report
Annual Inspection
Census: 25
Capacity: 40
Deficiencies: 3
Jun 25, 2025
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.
Findings
The inspection found two Type A deficiencies related to unlocked medication cart and improper storage of germicidal wipes near food, both posing immediate health and safety risks. Additionally, a Type B deficiency was cited for lack of accessible emergency drill documentation. Plans of correction were provided and deficiencies were cleared or pending documentation submission.
Severity Breakdown
Type A: 2
Type B: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Medication cart was unlocked and unattended while staff assisted another resident, posing an immediate health and safety risk. | Type A |
| Germicidal wipes were stored near the food counter in the kitchen, posing an immediate health and safety risk. | Type A |
| Emergency drill documentation was not accessible during the visit, posing a potential safety risk. | Type B |
Report Facts
Hot water temperature readings: Measured at 108, 106.2, 109.5, 108.3, 109.9, and 108 degrees Fahrenheit in residents' shared bathrooms.
Fire extinguisher last serviced date: 04/07/2025
Emergency Disaster Plan last posted date: 06/25/2025
Number of residents' records reviewed: 6
Number of staff records reviewed: 6
Number of residents' medication samples reviewed: 3
Plan of Correction due dates: Two Type A deficiencies due 06/26/2025; Type B deficiency due 07/09/2025.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffery Jackson | Health and Wellness Director | Met with Licensing Program Analyst during inspection. |
| Simone S Hall | Administrator/Director | Facility Administrator named in report. |
| Patricia Manalo | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on report. |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 40
Deficiencies: 0
Jun 19, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 01/14/2022 regarding resident care issues including timely showering and changing, staffing adequacy, and COVID-19 protocol adherence.
Findings
Based on interviews, observations, and records review, all four allegations were closed as unsubstantiated due to lack of evidence. No deficiencies were cited during the investigation.
Complaint Details
The complaint included allegations that residents were not showered or changed timely, residents' needs were unmet due to staffing shortages, and staff were not following COVID-19 protocols. The investigation found no substantiation for these claims.
Report Facts
Capacity: 40
Census: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Delmundo | Licensing Program Analyst | Conducted the complaint investigation |
| Bennett Fong | Licensing Program Manager | Oversaw the complaint investigation |
| Ebony Reed | Administrator | Facility administrator named in report header |
| Maria George | Dining Services Manager | Met with Licensing Program Analyst during investigation |
| Ryan Maltoni | Marketing Director | Granted entry to Licensing Program Analyst |
| Laura Eckert | Divisional Director of Operations | Spoke with Licensing Program Analyst by phone during investigation |
| S1 | Staff interviewed who served as pro tem cook during investigation | |
| PED | Previous Executive Director | Interviewed during investigation |
Inspection Report
Census: 25
Capacity: 40
Deficiencies: 0
Jun 6, 2025
Visit Reason
The visit was an unannounced case management inspection conducted in response to a death report received on 2025-06-02 regarding a resident found unresponsive.
Findings
The inspection found no deficiencies. The resident had multiple falls in recent months without apparent injuries, and the facility had implemented increased staff check-ins at night. The Executive Director will obtain and provide a death certificate to the Licensing Program Analyst.
Report Facts
Time of visit start: 1150
Time of visit end: 1250
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Simone Hall | Executive Director | Met with Licensing Program Analyst during inspection and discussed resident care and incident |
| Patricia Manalo | Licensing Program Analyst | Conducted the case management visit |
| Yvonne Flores-Larios | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 40
Deficiencies: 0
Feb 19, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that facility staff did not ensure medications were dispensed as prescribed.
Findings
The investigation included interviews and document reviews, revealing that a hospice nurse administered medication to the wrong resident. However, there was insufficient evidence to prove the alleged violation occurred, and the allegation was unsubstantiated. No deficiencies were cited during the visit.
Complaint Details
The complaint was unsubstantiated due to lack of preponderance of evidence despite the allegation that medications were not dispensed as prescribed.
Report Facts
Capacity: 40
Census: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Simone Hall | Executive Director | Met with Licensing Program Analysts during the investigation |
| Tonica Syess-Gibson | Licensing Program Analyst | Conducted the complaint investigation |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 40
Deficiencies: 0
Feb 11, 2025
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that staff did not provide adequate supervision, resulting in a resident sustaining multiple falls and injuries.
Findings
The investigation included interviews and review of resident and hospice records. The data collected did not confirm the allegation, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged inadequate staff supervision leading to multiple falls and injuries of Resident R1. After investigation, the allegation was found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 40
Census: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Simone Hall | Executive Director | Met during investigation and named in relation to the complaint |
| James Sampair | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 40
Deficiencies: 0
Jan 30, 2025
Visit Reason
Unannounced complaint investigation visit conducted to investigate allegations including staff yelling at residents, rough handling, medication mismanagement, unmet diapering and hygiene needs, and short staffing.
Findings
All six allegations were found to be unsubstantiated or unfounded after interviews, file reviews, and observations. No deficiencies were cited and the complaint was closed without findings of violations.
Complaint Details
The complaint included allegations of staff yelling at residents, rough handling, mismanagement of medication, unmet diapering and hygiene needs, and short staffing. The investigation involved interviews with staff, residents, witnesses, and review of medication records and staff training. The complaint was determined to be unsubstantiated or unfounded with no deficiencies cited.
Report Facts
Facility capacity: 40
Census: 29
Number of allegations: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Delmundo | Licensing Program Analyst | Conducted the complaint investigation |
| Simone Hall | Executive Director | Met with Licensing Program Analyst during investigation |
| Ebony Reed | Administrator | Facility administrator named in report |
Inspection Report
Annual Inspection
Census: 27
Capacity: 40
Deficiencies: 0
Jul 23, 2024
Visit Reason
The visit was an unannounced annual inspection conducted by Licensing Program Analysts to evaluate the facility's compliance with regulatory standards.
Findings
The facility was inspected thoroughly including physical plant, resident and staff records, and safety equipment. No deficiencies were cited during the visit.
Report Facts
Residents records reviewed: 6
Staff records reviewed: 4
Fingerprint clearance: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Simone Hall | Executive Director | Met with Licensing Program Analysts during inspection |
| Jill Clancy-Czuleger | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 40
Deficiencies: 0
Jun 13, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that a resident fell multiple times due to staff neglect resulting in injuries.
Findings
The investigation found that the resident's falls were not due to staff neglect but rather a decline in the resident's health. No deficiencies were cited during the visit.
Complaint Details
The complaint was unsubstantiated. The investigation included interviews, review of staff schedules, client rosters, physician's reports, and hospice notes. Progress notes indicated ongoing discussions with the resident's responsible party about increased needs.
Report Facts
Capacity: 40
Census: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Simone Hall | Executive Director | Met with Licensing Program Analyst during the investigation |
| Laura Hall | Licensing Program Analyst | Conducted the complaint investigation visit |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 25
Capacity: 40
Deficiencies: 0
Jul 26, 2023
Visit Reason
Unannounced 1-Year Annual Required Inspection conducted to evaluate facility compliance with licensing requirements.
Findings
The facility was found to be in compliance with no deficiencies cited. The environment was safe and well-maintained, with adequate lighting, temperature control, and safety equipment. Staff and resident records were current and medications reviewed without issue.
Report Facts
Bedrooms: 20
Bathrooms: 22
Non-ambulatory residents approved: 30
Bedridden residents approved: 10
Hot water temperature: 105.3
Administrator certificate expiration: Sep 6, 2023
Fire extinguisher last serviced: May 4, 2023
Staff records reviewed: 10
Resident records reviewed: 10
Resident medications reviewed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angie R. Chaney | Administrator | Met with Licensing Program Analyst during inspection and named in report |
| Liridon Fici | Licensing Program Analyst | Conducted the inspection and signed the report |
| Harpreet Humpal | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 22
Capacity: 40
Deficiencies: 0
Dec 9, 2022
Visit Reason
The visit was an unannounced case management inspection conducted due to an incident that occurred on 2022-11-08.
Findings
The investigation found no injuries, bruising, or marks on the resident involved in the incident. No deficiencies were cited during the visit. The companion of the resident involved was barred from the facility following the incident.
Complaint Details
The visit was triggered by a complaint related to an incident on 2022-11-08. The complaint was investigated and closed on the same day. No substantiation of injury or harm was found.
Report Facts
Incident date: Nov 8, 2022
Report submission date: Nov 14, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angie R. Chaney | Administrator | Interviewed regarding the incident and present during the visit |
Inspection Report
Annual Inspection
Census: 26
Capacity: 40
Deficiencies: 0
Aug 18, 2022
Visit Reason
An unannounced Annual Infection Control Visit was conducted to evaluate the facility's compliance with infection control standards.
Findings
The inspection found the facility to be in compliance with infection control requirements, including sufficient PPE supplies, proper signage, locked sharps and toxins, frequent disinfection of common areas, and operable safety equipment. No deficiencies were cited during the visit.
Report Facts
Water temperature: 115.6
Fire extinguisher last serviced: Apr 25, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angie Chaney | Administrator | Met during inspection and exit interview |
| Chiquita Morris | Health and Wellness Director | Met during inspection and exit interview |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 40
Deficiencies: 0
Dec 8, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility prevented contact with a resident's family.
Findings
The investigation included interviews with staff, witnesses, and the complainant, and review of relevant documents. It was found that family members were able to have FaceTime and in-person visits with residents, with visits scheduled and temperature screening conducted. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that the facility prevented contact with a resident's family. The allegation was unsubstantiated after investigation.
Report Facts
Capacity: 40
Census: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ebony Reed | Executive Director | Met with Licensing Program Analysts during the investigation |
| Lisha Holmes | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Routine
Census: 31
Capacity: 40
Deficiencies: 0
Jul 30, 2021
Visit Reason
The visit was an unannounced infection control inspection conducted as a required one-year routine check.
Findings
The inspection found the facility compliant with infection control standards, including proper signage, sufficient PPE and supplies, COVID-19 screening, and functioning safety detectors. No deficiencies were cited during the visit.
Report Facts
Capacity: 40
Census: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ebony Reed | Administrator | Met with Licensing Program Analysts during inspection |
| Allison O'Hollaren | Licensing Program Analyst | Conducted the infection control inspection |
| J. Clancy-Czuleger | Licensing Program Analyst | Conducted the infection control inspection |
| Yvonne Flores-Larios | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 40
Deficiencies: 0
Jan 25, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint alleging that the facility does not follow regulation on medical assessment.
Findings
The investigation found the allegation to be unfounded after reviewing records and conducting interviews, confirming that the responsible party completed and submitted the required physician's report form which was accepted by the facility.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegation was false, could not have happened, and/or was without reasonable basis.
Report Facts
Capacity: 40
Census: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Allison O'Hollaren | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Ivette Colondres | Administrator | Facility administrator met with during the investigation |
| Harpreet Humpal | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 40
Deficiencies: 1
Dec 8, 2020
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-10-19 regarding a resident wandering from the facility.
Findings
The investigation confirmed that a resident (R1) left the facility unassisted on 2020-10-13, which was substantiated as a violation of CCR title 22. The facility reported the incident to the licensing authority and was cited for failure to monitor residents adequately, posing an immediate threat to resident health and safety.
Complaint Details
The complaint was substantiated based on observations, records review, and interviews. The allegation was that a resident wandered from the facility unassisted, which was confirmed during the investigation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to monitor residents to prevent those who cannot leave unassisted from exiting the facility, posing an immediate threat to health and safety. | Type A |
Report Facts
Capacity: 40
Census: 30
Plan of Correction Due Date: Dec 9, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Allison O'Hollaren | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Harpreet Humpal | Licensing Program Manager | Oversaw the complaint investigation report |
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