Country Drive Post Acute
2500 Country Drive, Fremont, CA 94536 · Alameda County · 126 certified beds · avg 112 residents/day · certified since Mar 11, 1968
Part of chain: WINDSOR (22 facilities, chain avg rating 2.4★)
3/5
Health inspection rating (on-site)
1
Serious findings on record
$0
Fines, last 3 years
3.64
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Mar 6, 2025 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 14, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (36)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 23, 2026 | E · Potential for harm, repeated | The facility did not give residents the required written notice of their rights, the facility's rules, the services offered, and what those services cost. · from a complaint |
| Feb 23, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. · from a complaint |
| Feb 23, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to manage their own money and financial affairs. · from a complaint |
| Feb 23, 2026 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Aug 8, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Apr 24, 2025 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Apr 24, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 24, 2025 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Apr 24, 2025 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Apr 24, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 6, 2025 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| May 18, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 18, 2023 | E · Potential for harm, repeated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| May 18, 2023 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| May 18, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| May 18, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| May 18, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 18, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 18, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| May 18, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Mar 21, 2019 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Mar 21, 2019 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 21, 2019 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Mar 21, 2019 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Mar 21, 2019 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Mar 21, 2019 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Mar 21, 2019 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 21, 2019 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Mar 21, 2019 | E · Potential for harm, repeated | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| Mar 21, 2019 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 21, 2019 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 21, 2019 | E · Potential for harm, repeated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Mar 21, 2019 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Mar 21, 2019 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Mar 21, 2019 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Mar 21, 2019 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (9 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 16 | 0 | E |
| 2023 | 9 | 0 | F |
| 2025 | 7 | 1 | G ▲ |
| 2026 | 4 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.64 | 4.31 | 3.95 | bottom 17% in California; bottom 43% in the U.S. |
| Registered Nurse hours | 0.67 | 0.61 | 0.69 | top 27% in California; top 40% in the U.S. |
| Weekend total nurse staffing | 3.50 | 3.90 | 3.50 | bottom 31% in California; top 42% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.69 | 0.51 | 0.48 | top 15% in California; top 17% in the U.S. |
| Total nursing staff turnover (%) | 31.8 | 36.7 | 45.8 | top 37% in California; top 18% in the U.S. |
| RN turnover (%) | 18.8 | 38.1 | 42.9 | top 18% in California; top 12% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.75, RN 0.69, weekend 3.61. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Antelope Holdings I, LLC | Organization | 5% or Greater Direct Ownership Interest | — | 06/30/2023 |
| Antelope Realty Holdings I, LLC | Organization | 5% or Greater Direct Ownership Interest | — | 11/08/2024 |
| Robin, Aaron | Individual | 5% or Greater Indirect Ownership Interest | 50% | 06/30/2023 |
| Tress, Avrohom | Individual | 5% or Greater Indirect Ownership Interest | 50% | 06/30/2023 |
| Windsor Norcal 13 Holdings LLC | Organization | 5% or Greater Direct Ownership Interest | — | 04/01/2007 |
| Couto, Dorothy | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/20/2024 |
| Couto, Dorothy | Individual | ADP of the SNF | NOT APPLICABLE | 03/20/2024 |
| Newgen Administrative Services, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/30/2023 |
| Robin, Aaron | Individual | Corporate Officer | NOT APPLICABLE | 08/14/2023 |
| Shaw, Pamela | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/30/2023 |
| Shaw, Pamela | Individual | ADP of the SNF | NOT APPLICABLE | 06/23/2023 |
| Tress, Avrohom | Individual | Corporate Officer | NOT APPLICABLE | 08/14/2023 |
| Win, Htay | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2024 |
| Win, Htay | Individual | ADP of the SNF | NOT APPLICABLE | 02/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Can I get a written copy of resident rights, house rules, and a full list of services and charges today?"
- "How do you handle room assignments and roommate requests, and do residents get advance written notice before any move?"
- "How are residents' personal funds handled here, and what records can families review?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Crestwood Treatment Center | 0.0 mi | Fremont, CA | ★★★★★ | 4/5 | |
| We Care Skilled Nursing - Fremont | 0.1 mi | Fremont, CA | ★★★☆☆ | 3/5 | |
| Mission Valley Post Acute | 0.1 mi | Fremont, CA | ★★★★☆ | 3/5 | |
| Niles Canyon Post Acute | 1.0 mi | Fremont, CA | ★★★★★ | 5/5 | |
| Fremont Healthcare Center | 1.1 mi | Fremont, CA | ★★★★☆ | 3/5 | |
| Crestwood Manor - Fremont | 1.4 mi | Fremont, CA | ★★★★★ | 5/5 | |
| Masonic Home | 3.4 mi | Union City, CA | ★★★★☆ | 4/5 | |
| Eden Healthcare Center | 7.6 mi | Hayward, CA | ★★☆☆☆ | 2/5 | abuse |
| Emmanuel Post Acute Care - Hayward | 7.9 mi | Hayward, CA | ★★★☆☆ | 2/5 | |
| Hayward Post Acute | 8.2 mi | Hayward, CA | ★★★★☆ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 055885.