Inspection Reports for Fremont Village

The visit was an unannounced Case Management visit conducted to confirm receipt of the Default Decision and Order for Staff 1 (S1) and to verify staff association with the facility.

The Licensing Program Analysts confirmed that the Default Decision and Order document for Staff 1 was received by the facility. Staff interviews and record reviews verified that Staff 1 was from an outside agency and is no longer associated with the facility. No deficiencies were cited during this visit.

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

The facility was found to have multiple deficiencies including unlocked hazardous substances accessible to residents, items in disrepair, hot water temperature out of range, expired food products, unlabeled food items, pre-poured medications, and lack of updated resident appraisal plans. Plans of correction were agreed upon with specified due dates.

The visit was an unannounced 1-Year Annual Required inspection conducted by Licensing Program Analysts to evaluate the facility's compliance with licensing requirements.

The inspection was initiated and partially completed on 09/19/2025, with the Licensing Program Analysts planning to return at a later date to complete the annual inspection. The facility's fire clearance was approved for a capacity of 120 residents, including allowances for non-ambulatory, bedridden, and hospice waiver residents.

The visit was an unannounced case management visit conducted by Licensing Program Analyst P. Manalo to review compliance with licensing requirements.

During the visit, it was observed that the facility's admission agreement did not include the visitation policy and isolation policy. The Administrator and LPA discussed regulations on personal rights regarding visits and visitation plans for residents with roommates. A technical advisory was issued on the date of the visit.

An unannounced complaint investigation was conducted regarding an allegation that staff prohibit resident visitation.

The investigation found that residents’ families can schedule appointments for visitation and visit during visiting hours without issues. Interviews and document reviews did not substantiate the allegation. No deficiencies were noted.

The allegation that staff prohibit resident visitation was unsubstantiated based on interviews with staff, witnesses, family members, and review of facility policies and documents.

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

The Licensing Program Analyst toured the facility and found no deficiencies. All safety equipment, hot water temperatures, lighting, food supplies, and medication storage were in compliance with regulations.

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

An unannounced Case Management visit was conducted regarding a self-reported incident where a resident went AWOL by exiting through a window on 06/03/2025. The visit aimed to investigate the incident and assess compliance with safety regulations.

The investigation found that the auditory alarm on the window was functioning but may have been turned off by staff at the time of the incident. The window's auditory signal was displaced, the windowsill was broken, and there was rust on the closet panel in the resident's room. These conditions posed potential safety risks.

The visit was complaint-related due to a self-reported incident of a resident going AWOL. The complaint was substantiated by findings of safety and maintenance deficiencies.

An unannounced Plan of Correction (POC) visit was conducted to verify correction of a previously issued deficiency related to a malfunctioning freezer thermostat noted during the annual visit on 10/29/2024.

The visit confirmed that the freezer thermostat was functioning properly with no deficiencies cited during this inspection.

The visit was an unannounced case management follow-up inspection conducted due to an incident reported to the Community Care Licensing Division on 2024-11-11.

No deficiencies were cited during the visit. Licensing Program Analysts reviewed various resident and facility documents and requested updated physician reports and other documentation to be submitted by 2024-12-13.

The inspection was an unannounced 1-Year Annual Required inspection conducted to assess compliance with licensing regulations and facility safety standards.

The facility was found to have a malfunctioning freezer thermostat, outdated appraisal and service plans for residents R1 to R6, and a staff member (S6) not associated with the facility. Fire safety equipment and emergency plans were in place and up to date. Plans of correction were agreed upon for all deficiencies.

The visit was an unannounced case management inspection conducted in response to an Unusual Incident Report submitted by the facility.

The report found that a resident (R1) was sent to the hospital for an open wound on the coccyx area due to refusal of care, was transferred to a Skilled Nursing Facility until healed, and then readmitted to the facility. No deficiencies were cited during the visit.

An unannounced complaint investigation was conducted in response to allegations that a resident sustained an unexplained bruise while in care and that staff did not properly supervise the resident.

The investigation found no evidence that the resident was a fall risk or that neglect or lack of supervision occurred. The resident's death was due to natural causes with no signs of trauma or foul play. The allegations were unsubstantiated and no deficiencies were noted.

The complaint investigation was unsubstantiated based on interviews, record reviews, and reports from the Fremont Fire Department and Alameda County Coroner’s Bureau. There was no preponderance of evidence to prove the alleged violations occurred.

The visit was conducted as a case management investigation related to complaint #15-AS-20230718143211 regarding the care provided to resident R1 who was found unconscious.

The investigation found that staff member S2 failed to perform CPR immediately on R1 and delayed calling 911 until 5:21 am, despite R1 being found unresponsive at 5 am. A deficiency was cited for failure to meet the requirement to immediately call 911 in a life-threatening medical crisis.

Investigation of complaint #15-AS-20230718143211 found substantiated issues with delayed CPR and delayed 911 call for resident R1 who was found unconscious at 5 am.

The visit was an unannounced complaint investigation conducted in response to allegations received on 06/28/2023 regarding staff behavior, hygiene assistance, dental care timeliness, and cleanliness of residents' rooms.

After interviews with residents and staff, and review of records including care plans and dental logs, the investigation found no preponderance of evidence to substantiate the allegations. Staff were confirmed to assist with daily living activities, maintain cleanliness, and arrange dental care as needed. The allegations were determined to be unsubstantiated.

The complaint included allegations that staff spoke inappropriately to a resident, failed to assist with hygiene needs, did not seek timely dental care, and did not ensure residents' rooms were clean. The investigation found these allegations unsubstantiated based on interviews and record reviews.

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

The facility was found to be in compliance with no deficiencies cited. The inspection included a tour of the facility, review of staff and resident records, and medication review. Several updated documents were requested for submission by 9/15/2023.

The inspection was conducted as a result of a priority 2 complaint to perform a Health & Safety inspection.

The facility was toured including bedrooms, bathrooms, common areas, kitchen, and outdoor area. All safety measures such as hot water temperature, food supplies, refrigerator and freezer temperatures, medication security, smoke and carbon monoxide detectors, first-aid kit, and fire extinguisher were found to be in compliance. No deficiencies were cited during the visit.

The visit was triggered by a priority 2 complaint. No deficiencies were found, indicating no substantiated violations.

The visit was an unannounced infection control inspection conducted as a required 1-year routine check.

The inspection found the facility well-maintained with sufficient PPE, proper signage, adequate supplies, and no deficiencies cited. Common areas were disinfected three times daily, and safety equipment was properly maintained.

Unannounced complaint investigation conducted due to allegations regarding facility heating and cooling system disrepair and presence of roaches.

The allegation of the heating system being in disrepair was substantiated, with evidence of an inoperable heater posing a potential health and safety risk. The allegation of roaches was unsubstantiated as pest control measures were in place and the issue was being addressed.

The complaint investigation was substantiated for the allegation that the facility heating and cooling system is in disrepair, specifically an inoperable heater in resident R5's room. The allegation regarding roaches was unsubstantiated due to ongoing pest control efforts and lack of sufficient evidence.

The inspection was an unannounced complaint investigation visit triggered by allegations of staff neglect resulting in the death of a resident and failure to notify the responsible party.

The investigation found that the allegations were unsubstantiated. The resident was observed with clothing and the pendant was tied around the rails per resident preference. The facility had contacted the responsible party despite the complainant's claim otherwise.

The complaint involved allegations of staff neglect resulting in the death of a resident and failure to notify the responsible party. The allegations were determined to be unsubstantiated due to insufficient evidence.

Unannounced infection control inspection conducted as a required 1-year visit to assess compliance with infection control and food service regulations.

The inspection found that the facility generally maintained infection control measures including posted COVID-19 signs, sufficient PPE, and regular disinfection. However, a deficiency was cited due to two cartons of Lactaid in the refrigerator that expired on August 10, 2021, posing a potential health and safety risk.

The visit was an unannounced case management inspection conducted regarding an incident report received on 2021-07-09 involving a resident who left the facility without authorization.

The inspection found that a resident exited the facility through a torn screen window and was missing for approximately one hour before being found and returned. Deficiencies were cited related to resident safety and record-keeping, posing immediate and potential health and safety risks.

The visit was triggered by an incident report regarding a resident who left the facility during an activity and was missing for about one hour. The complaint was substantiated by observations and interviews.