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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601374
Report Date: 02/20/2025
Date Signed: 02/20/2025 02:55:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2024 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20240409165559
FACILITY NAME:AEGIS ASSISTED LIVING OF FREMONTFACILITY NUMBER:
015601374
ADMINISTRATOR:PAUL H SHEPODDFACILITY TYPE:
740
ADDRESS:3850 WALNUT AVENUETELEPHONE:
(510) 739-1515
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:110CENSUS: 75DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Ryan Turner, Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident sustaining multiple fractures while in care
INVESTIGATION FINDINGS:
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On 02/20/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit to deliver the finding of the allegation. LPA explained the purpose of the visit with Executive Director/Administrator (ADM).

During investigation, the department obtained the following documents from administrator – staff roster with contact information, LIC500, resident roster, admission agreement, physician's report, preplacement appraisal, hospice care plan, emergency information, responsible party (POA) information, home heath reports, incident reports. Health & safety check conducted see LIC 809 dated 04/11/24.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20240409165559
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FREMONT
FACILITY NUMBER: 015601374
VISIT DATE: 02/20/2025
NARRATIVE
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ALLEGATION:
Neglect/Lack of Supervision – Staff did not provide adequate supervision resulting in resident (R1) sustaining multiple fractures while in care.
INVESTIGATION FINDING: Substantiated
During investigation, the department conducted interviews of facility staff (Care Director (CD), Regional Health Services Director (RHD), S1, S2) & R1’s responsible party (POA) and reviewed resident (R1) documents. Review of R1’s incident reports showed R1 had sustained 5 documented falls at the facility since she was admitted in 2022. Staff (CD, RHD) both denied receiving reports from care staff that R1 needs a 1:1 caregiver citing R1 higher level of care. Despite having multiple fall prevention methods in place and staff expressing their concerns to management in not being able to provide adequate care, R1 continued to have un-witnessed and witnessed falls in the facility, twice sustaining serious fractures in her femur and pelvis,

Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that staff did not provide adequate supervision resulting in resident (R1) sustaining multiple fractures while in care. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated.

Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in resident sustaining multiple fractures while in care.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.



Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240409165559
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 FREMONT
FACILITY NUMBER: 015601374
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2025
Section Cited
CCR
87468.2(a)(4)
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To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Deficiency corrected during visit.
In-service staff retraining on proper care and supervision conducted on 04/12/24.
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This requirement was not met as evidenced by staff failing to provide adequate supervision resulting in resident sustaining multiple fractures while in care which posed an immediate risk to resident in care.
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Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in resident sustaining multiple fractures while in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
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