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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601374
Report Date: 08/19/2024
Date Signed: 08/19/2024 03:11:32 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
07/03/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230703170031
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:
08/19/2024
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Ryan Turner, General ManagerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident sustained an injury while in care
Staff did not report the incident to CCL
INVESTIGATION FINDINGS:
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On 08/19/2024 at 2:40 PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger and P. Manalo arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with General Manager Ryan Turner and HSD Leslie Ibo.

On the allegation: Resident sustained an injury while in care. RP states that R1 was found on the floor in fetal position. When R1 was admitted to the ER imaging was done showing that R1 had traumatic subarachnoid hemorrhage with no acute fracture or malalignment identified. R1’s medical records state that this injury is constant with an accidental fall.

Staff did not report the incident to CCL. The facility provided an incident report dated 6/4/2022 for R1 which details the incident of R1 getting sent to the hospital for a UTI and returning to the facility on 6/3/22 after being admitted to hospice. The incident report did not report the subarachnoid hemorrhage that was found at the hospital as a result of an unwitnessed fall.
Continued on LIC9099-C...
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: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
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
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
07/03/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230703170031

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:
08/19/2024
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Ryan Turner, General ManagerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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2
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9
Staff did not communicate with the responsible party of incident
Staff did not seek medical attention for resident.
INVESTIGATION FINDINGS:
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On 08/19/2024 at 2:40 PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger and P. Manalo arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with General Manager Ryan Turner and HSD Leslie Ibo.

On the allegation: Staff did not communicate with the responsible party of incident. Based on interviews and record reviews R1’s family were the ones who brought it to staff’s attention that R1 was feeling paint when peeing.

On the allegation: Staff did not seek medical attention for resident. Based on interviews and record reviews facility staff did a dipstick test for R1, which indicated a possibility of UTI at which time the facility informed the family and PCP. R1’s subarachnoid hemorrhage was found at the hospital after additional tests were done and it was determined that the injury was from an unwitnessed fall.
Continued on LIC9099-C...
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: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20230703170031
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: 08/19/2024
NARRATIVE
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...Continued from LIC9099-A

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted 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: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20230703170031
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: 08/19/2024
NARRATIVE
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....Continued from 9099

Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 has been cited.



Exit interview conducted. A copy appeal rights, and this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 15-AS-20230703170031
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: 08/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2024
Section Cited
CCR
87211(a)(1)(B)
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(a)Each licensee shall furnish to the licensing agency such reports... (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidenced by:
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Licensee will submit a written certification indicating the understanding of reporting requirements.

Civil penalty assessed of $250 for repeat violation.
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Based on reports the licensee did not comply with the section cited above by not submitting an incident report involving an injury resident sustained from accidental fall.
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Type B
08/26/2024
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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Licensee will submit a written certification indicating the understanding of the regulation.

Civil penalty assessed of $250 for repeat violation.

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This requirement is not met as evidenced by: Based on interviews and records review, the facility did not observe R1 close enough to know that he had a fall resulting in injury.
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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: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5