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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601374
Report Date: 07/10/2024
Date Signed: 07/10/2024 10:40:18 AM

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
06/14/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230614155123
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: 80DATE:
07/10/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Ryan Turner Genral Manager TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not seek medical attention to resident
Staff did not report incident to CCL
Staff did not communicate with the responsible party of incident
INVESTIGATION FINDINGS:
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On July 10, 2024 at 9:10 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings on the above allegations. LPA met with Ryan Turner Genral Manager and Kevin Hunter SVPO and explained the reason for the visit.

The Department’s investigation included but was not limited to interviews with staff, residents, and the reporting party. The Department obtained copies of resident (R1) record, pictures of R1’s bruising, Medical Records, Text message exchange and Death Certificate.

On the allegation: Staff did not seek medical attention to resident.
Based on Interview On June 16, 2022, R1 had two unwitnessed falls that occurred around 0825 AM and 1120 AM. The information about these two falls was provided by S2 to her leadership (S1) about five days after the incident occurred.

Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
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 5
Control Number 15-AS-20230614155123
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: 07/10/2024
NARRATIVE
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...Continued from LIC 9099

The first unwitnessed fall was discovered by S2; documents support that care staff (caregivers) helped R1 up and provided first aid to her finger. The second unwitnessed fall, S1 delayed reported that around 1120 hours, she observed R1 on the floor in front of a chair she was previously sitting on at around 1100 hours. Staff assisted R1 to her feet and, as per interviews, guided her back to the dining area before later presenting her to her family for a visit. Care staff did not notify the nurse on duty for additional assessment for both unwitnessed falls.

On the allegation: Staff did not report incident to CCL.

Based on interviews and records review the facility did not report to the department that R1 had 2 unwitnessed falls on June 16, 2022. In an interview with S1 said that for both falls reported by S2, facility was not able to find the incident reports or the COC report to provide to CCLD.

On the allegation: Staff did not communicate with the responsible party of incident.

Based on interviews and records review the facility did not report to R1’s family the residents change of condition or falls that occurred. In an interview with the investigator S1 confirmed that no one updated R1’s family about the investigation.

Based on the investigation, above allegations are deemed Substantiated.

A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
06/14/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230614155123

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: 1DATE:
07/10/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Ryan Turner Genral Manager TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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On July 10, 2024 at 9:10 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings on the above allegation.
On the allegation: Resident sustained unexplained injuries while in care
On June 16, 2022, R1 had two unwitnessed falls that occurred around 0825am and 1120am.The information about these two falls was provided by S2 to S1. The first unwitnessed fall was discovered by S2, documents support that care staff (caregivers) helped R1 up and provided first aid to her finger.The second unwitnessed fall, S2 delayed reported that around 1120 AM, she observed R1 on the floor in front of a chair she was previously sitting on around 1100 AM. R1 was not listed as fall risk, and she was able to walk around the facility on her own.

Based on the investigation, above allegation will be deemed Unsubstantiated.
A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
Exit interview conducted and copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20230614155123
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: 07/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2024
Section Cited
CCR
87465(g)
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The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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The administrator agreed to have an in-staff training to review regulation 87465(g). The facility will submit a copy of the training topic with attendees’ signatures and will be abided by going forward to CCLD by POC date.
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This requirement is not met as evidenced by:
Based on interviews and records review, the facility did not seek medical attention for a resident who had two falls.
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CCR
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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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20230614155123
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: 07/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2024
Section Cited
CCR
87211(a)(1)(B)
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Each licensee shall furnish to the licensing agency such reports as the Department ... A written report shall be submitted to the licensing agency ... This report shall include... Any serious injury as determined by the attending physician... This requirement was not met and evidenced by:
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The administrator agreed to have an in-staff training to review regulation 87211. The facility will submit a copy of the training topic with attendees’ signatures and will be abided by going forward to CCLD by POC date.
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Based on interviews and records review, the facility did not report to the department that the resident had bruising and two unwitnessed falls.
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Type B
07/24/2024
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, ... the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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The administrator agreed to have an in-staff training to review regulation 87466. The facility will submit a copy of the training topic with attendees’ signatures and will be abided by going forward to CCLD by POC date.
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This requirement is not met as evidenced by: Based on interviews and records review, the facility did not for a resident who had two falls.
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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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5