John C. Fremont Healthcare District DP/SNF

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.01 therapist hours per resident per day in 2026Q1 — more than 0% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 68% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 16 beds and averages 15.5 residents a day — about 97% occupied, or roughly 0 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 6.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.80 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 5.55 hrs/resident/day on weekends vs 6.93 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.85 to 0.03 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

15 citations, most serious first. The 10 most serious are shown; the remaining 5 are one tap away and print in full.

• Potential for harm · F2026-02-10 · tag F0801 — widespread
  Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to ensure dietary services were directed by a qualified Certified Dietary Manager (CDM) for 15 of 15 residents, when the facility CDM's certification expired on 6/1/25.This failure resulted in a lack of oversight by a qualified Certified Dietary Manger, which had the potential risk to affect food safety, infection control practices, and the nutritional well-being of residents. Findings:During an interview on 2/6/26 at 8:35a.m. with the Cook, the [NAME] stated the CDM was her supervisor and all kitchen staff reported to the CDM. The [NAME] stated the CDM conducted all training for the kitchen staff.During an interview on 2/6/26 at 8:39a.m. with the CDM, the CDM stated her CDM license had lapsed on 6/1/25. The CDM stated she was required to submit all continuing education hours to the certifying board of dietary managers (CBDM) by 5/31/25 and her license was required to be renewed every three years. The CDM stated she reported to the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-02-10 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection prevention and control program when: 1. The Environmental Services Staff (EVSS) failed to handle, store, and process residents' personal clothing to prevent the spread of infection. 2. The facility's written policies and procedures (P&P) for infection prevention and control program (IPCP) -a set of facility's policies and procedures aimed at preventing the spread of infection) was not reviewed annually by the infection control committee members with last reviewed date of 3/8/23.These failures placed residents at risk for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect), spread of infectious diseases resulting in healthcare associated infections, and systemic infection control breakdown due to lack of annual program review. 1.During a concurrent observation and interview on 2/6/26 at 8:51 a.m. with Licensed Vocational Nurse (LVN) 2, in the laundry…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-02-10 · tag F0940 — failed to train staff — widespread
  Develop, implement, and/or maintain an effective training program for all new and existing staff members.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to implement and maintain an effective training program for all staff when an Environmental Services Staff did not receive training for proper handling, storing, and processing of residents' personal clothing for more than a year.These failures to follow proper practices in handling, storing, and processing of residents' personal clothing had the potential to result in an increased risk of cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and developing an avoidable facility acquired infection (the invasion of the body by harmful microorganisms). During a concurrent observation and interview on 2/6/26 at 8:51 a.m. with Licensed Vocational Nurse (LVN) 2, in the laundry room, the dirty hamper was widely open with overflowing of bagged soiled and dirty residents' personal clothing, and a container of cookies was on the top of the counter. LVN 2 stated the dirty hamper should not be overflowing and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-02-10 · tag F0658 — failed to meet professional standards of care — pattern
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow policy and procedures (P&P) for Medication Administration to meet professional standards of quality for two of six sampled residents (Resident 3 and 13) when Licensed Vocational Nurse (LVN) 1 did not use two resident identifiers prior to administering medications and did not explain the name and indication of the medications being administered for Resident 13 and Resident 3. These failures placed Resident 13 and Resident 3 at risk for medication errors, unrecognized adverse drug reactions, and decrease compliance.During an observation on 2/5/26 at 1:17 p.m. with LVN1, outside Resident 13's room, LVN 1 parked the medication cart, knocked on Resident 13's door and informed Resident 13 she will administer her afternoon medications. LVN 1 started preparing Resident 13's 2:00 p.m. medications on top of the medication cart. LVN 1 placed two tablets of Vaccinium macrocarpon (dietary supplement used to support urinary tract health), one…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-02-10 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews and record reviews, the facility failed to ensure food stored in the resident refrigerator was consistently monitored and maintained to prevent expired items from being available to residents.This failure affected all 15 residents, as they all received food provided by the facility, and placed them at risk for foodborne illness. Findings:During an observation on 2/4/26 at 1:28p.m. of the resident refrigerator located at the nurses' station, two cartons of milk were observed with use by dates of 2/3/26.During an interview on 2/5/26 at 11:42a.m. with the Certified Dietary Manager (CDM), the CDM stated the process for stocking the resident refrigerator involved skilled nursing facility (SNF) staff completing a request form for needed items. The CDM stated kitchen staff prepared the requested items and delivered them to the SNF unit. The CDM stated the SNF staff were responsible for maintaining the refrigerator and its contents, including monitoring and documenting refrigerator temperatures. The CDM stated once the food items were delivered from the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-10 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the Office of the State Long-Term Care Ombudsman (an independent official who assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preference) of the transfer or discharge for one of one resident sample resident (Resident 2) when Resident 2 was transferred to acute care hospital and discharged from the facility.This failure had the potential for Resident 2 not receiving due process and protection against improper discharge. During a record review of Resident 2's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 10/1/24, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), chronic obstructive…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-10 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for one of five sampled resident (Resident 1) when Resident 1's nutrition care plan for significant weight gain was not developed.This failure resulted in Resident 1 not being assessed for significant weight gain by qualified staff and had the potential for Resident 1 to experience unrecognized negative outcomes including fluid retention, decline in oral intake, worsening of shortness of breath, and decrease in functional mobility.During a concurrent observation and interview on 2/5/26 at 12:15 p.m. with Resident 1, in the dining room, Resident 1 was sitting in a reclining chair, lunch tray was served. Resident 1 was looking at her lunch tray, sitting back on her recliner chair, and was looking around the environment. Resident 1 was not eating her lunch meal. Resident 1 was alert and able to state her name, wearing glasses and well groomed. Resident 1 had difficulty in hearing…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-10 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to review and revise a comprehensive person-centered care plan to reflect assessments and interventions to address a significant weight changes for one of four sampled residents (Resident 1) when Resident 1's nutritional care plan was not revised to reflect Resident's 1's significant weight gain of more than five percent in 30 days and continued gradual weight gain. These failures had the potential for Resident 1 not to receive the necessary care and services and put Resident 1 at an increased risk of unintended weight gain. During a concurrent observation and interview on 2/5/26 at 12:15 p.m. with Resident 1, in the dining room, Resident 1 was sitting in a reclining chair, lunch tray was served. Resident 1 was looking at her lunch tray, sitting back on her recliner chair, and was looking around the environment. Resident 1 was not eating her lunch meal. Resident 1 was alert and able to state her name, wearing glasses and well groomed.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-10 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with the facility's policy and procedures (P&P) Medication Storage to meet professional standards of quality when the medication storage cabinet contained an expired medication with expiration date of 1/2026. This failure had the potential risk for residents to receive expired medications which could result in reduced therapeutic effectiveness, treatment failure and serious health complications. During a concurrent observation and interview on 2/5/25 at 11:03 a.m. with the Licensed Vocational Nurse (LVN) 1, in front of the medication storage cabinet, an unopen bottle of Fish Oil (used to reduce pain, improve morning stiffness and relieve joint tenderness in people with rheumatoid arthritis [a chronic autoimmune disorder where the immune system attacks joint linings (synovium), causing painful inflammation, stiffness, and potential deformity] 1000 mg (milligrams- metric unit of measurement, used for medication dosage and/or amount)…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-10 · tag F0908 — failed to keep essential equipment working — isolated
  Keep all essential equipment working safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure resident care equipment was maintained in safe and operating condition when the facility's shower chair was not functional to deliver residents' care and activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).This failure placed Resident 13 at risk for falls, skin injuries, equipment malfunction, and serious harm during bathing assistance. During a concurrent observation and interview on 2/4/26 at 1:39 p.m. with Resident 13, in Resident 13's room, Resident 13 was sitting on the left side of her bed watching television. Resident 13 was alert and oriented x 4 (names, time, places, and events/situation), pleasant, and well groomed. Resident 13 stated she had been at the facility for almost four years and had worked at the facility as a housekeeper. Resident 13 stated she was admitted to the facility because she needed assistance with…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 11 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in CA