015601374-10-28-2024-15-AS-JCCR-DAGUF8-20241028153218

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601374
Report Date: 10/28/2024
Date Signed: 10/28/2024 03:32:33 PM

Document Has Been Signed on 10/28/2024 03:32 PM - It Cannot Be Edited

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 FREMONT		FACILITY NUMBER:	015601374
ADMINISTRATOR/ DIRECTOR:	TURNER, RYAN		FACILITY TYPE:	740
ADDRESS:	3850 WALNUT AVENUE		TELEPHONE:	(510) 739-1515
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY: 110	TOTAL ENROLLED CHILDREN: 0	CENSUS: 68	DATE:	10/28/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Leslie Ibo, Health and Wellness Director		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPAs) Manalo and Clancy-Czuleger arrived unannounced to conduct a case management visit in response to the Unusual Incident Report (UIR) submitted by the facility. LPA's met with Leslie Ibo, Health and Wellness Director and Ryan Turner Executive Director and explained the purpose of the visit.

Resident (R1) had passed away on 10/17/2024. On October 20, 2024, Health and Wellness Director (S1) started the process of medication destruction, when it was observed that an unused bottle of narcotics medications was missing. Medtech’s and nurses started to look for the medication. All medication carts and overflow cabinets were searched and still could not find the medications.

An internal investigation was conducted, medtech’s and nurses was interviewed. The incident was reported to Fremont Police with the incident event number is P24125430. In-service with wellness team started on 10/22/2024 with the following topics: narcotic count, documentation, medication error, medication destructions and other topics.

Regional Health Services Director and General Manager was notified regarding the incident. Our community started to have two staff signing off for the narcotics, nurses will audit narcotics weekly.

No deficiency cited.

Exit interview conducted and copy of this report provided.

Harpreet Humpal	TELEPHONE: (510) 285-3928
Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

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

LIC809 (FAS) - (06/04)

Page: 1 of 1