015601374-11-15-2023-15-AS-KHOS-CY2RV7-20231129122105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601374
Report Date: 11/15/2023
Date Signed: 11/15/2023 11:22:14 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
05/23/2023 and conducted by Evaluator Liridon Fici

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230523081935

FACILITY NAME:	AEGIS ASSISTED LIVING OF FREMONT		FACILITY NUMBER:	015601374
ADMINISTRATOR:	PAUL H SHEPODD		FACILITY TYPE:	740
ADDRESS:	3850 WALNUT AVENUE		TELEPHONE:	(510) 739-1515
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	110	CENSUS: 80	DATE:	11/15/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Madeline Williams, General Manager (GM), and Shashi Madahar, Health Services Director (HSD)		TIME COMPLETED:	11:27 AM

ALLEGATION(S):

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Staff abused residents while in care.
Staff violated residents personal rights.

INVESTIGATION FINDINGS:

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On 11/15/2023, at 11:00 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a subsequent complaint investigation visit and to deliver findings on the above allegations. LPA was greeted by Madeline Williams, General Manager (GM), and Shashi Madahar, Health Service Director (HSD) and explained the purpose of the visit.

During the course of the investigation, LPA interviewed four (4) residents and five (5) staff members . LPA obtained the following documents: Staff and resident roster, Staff contact information, Facility staff schedule (May and June 2023), Residents Identification and Emergency Information (ID), Progress notes (May 2023), Physicians reports, and Incident reports (May 2023) of a sample of 5 of 5 residents.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230523081935

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AEGIS ASSISTED LIVING OF FREMONT	FACILITY NUMBER: 015601374
	VISIT DATE: 11/15/2023

NARRATIVE

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It was alleged that staff abused resident while in care and staff violated residents personnel rights. Based on interviews conducted. All staff have stated that they have not witnessed any residents’ being abused nor their personnel rights being violated. All staff gave residents’ their personal phone and call button to call as they please. Residents’ stated during interview that they are treated well, and staff has not abused them nor violated their personnel rights. Residents’ also stated that staff allows them to use their personal phones, and use the call button for assistance if they need any type of help. LPA review R1’s medical record which indicated R1 sustaining a fall resulting in a hip fracture in November 2021.

Based on Interviews and record review conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegations are UNSUBSTANTIATED.

Exit interview conducted with GM and HSD, and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

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