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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601374
Report Date: 11/19/2020
Date Signed: 11/19/2020 04:55:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AEGIS ASSISTED LIVING OF FREMONTFACILITY NUMBER:
015601374
ADMINISTRATOR:SHASHI K MADAHARFACILITY TYPE:
740
ADDRESS:3850 WALNUT AVENUETELEPHONE:
(510) 739-1515
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:110CENSUS: 81DATE:
11/19/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Dave Peper, General ManagerTIME COMPLETED:
04:50 PM
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On 11/19/2020 at 4:00PM, Licensing Program Analyst (LPA) G. Luk conducted a Case Management over the phone regarding death report due to shelter in place order directed by the Governor. LPA spoke to General Manager, Dave Peper

Based on the death report received on 11/18/2020, resident (R1) had a fall and sustained a head injury. R1 was sent to ER immediately. On 11/17/2020, family notify facility that R1 was found to have a punctured lung from a broken rib along with his head injury which was the cause of R1's passing.

Based on interview with care staff, S2 brought dinner to R1 at around 5:10PM and found R1 coughing. R1 was laying in bed leaning on one side of the bed. S2 stated the R1 was leaning and suddenly fell out of bed. R1 hit his head on the bed side table. S3 was called to assess R1's injuries and found bruising near right eye brow and on right elbow. S3 called R1's responsible party and 911. On 11/17/2020, facility received an email from R1's family notifying them of R1's passing.

LPA reviewed and obtained care plan, physician's report, and incident report.

No deficiencies are being cited on this date.

Exit interview conducted and a copy of this report will be emailed.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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