015601374-11-18-2022-15-AS-YFLS-CLV2RA-20221206163712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601374
Report Date: 11/18/2022
Date Signed: 11/18/2022 10:06:01 AM

Unsubstantiated

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
09/16/2022 and conducted by Evaluator Liridon Fici

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220916125605

FACILITY NAME:	AEGIS ASSISTED LIVING OF FREMONT		FACILITY NUMBER:	015601374
ADMINISTRATOR:	SHASHI K MADAHAR		FACILITY TYPE:	740
ADDRESS:	3850 WALNUT AVENUE		TELEPHONE:	(510) 739-1515
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	110	CENSUS: 82	DATE:	11/18/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Paul Shepodd- Administrator		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff handled resident in a rough manner, causing injury.
Staff did not respond to resident's request for assistance in a timely manner.
Staff did not seek medical attention for resident in a timely manner.
Facility retained resident needing a higher level of care.
Staff did not report an incident involving resident to their representative.

INVESTIGATION FINDINGS:

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On 11/18/2022 at 9:30 AM, Licensing Program Analysts (LPAs) Doni Fici and Catherine Lin arrived unannounced to delivery findings on the above allegations. LPAs were greeted by Paul Shepodd, Administrator (ADM), and Shashi Madahar, Health Services Director (HSD).

During the course of the investigation, LPAs reviewed and obtained documents, incident reports, physician reports, physician orders, care notes, Personal Help Button (PHB) call log, and performed 4 of 4 interviews with community staff, and resident.

Continue on Lic9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

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-20220916125605

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: 11/18/2022

NARRATIVE

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It was alleged that staff handled resident in a rough manner, causing injury. Based on interviews with 4 of 4 staff members, staff demonstrated how to pick up a resident that needs assistance after a resident has a fall. R1 had a fall on 12/19/2019, and an incident report was received on 12/19/2019. R1 sustained a knee injury due to R1 falling. Staff also informed LPA what the facility procedures were when handling a resident in care that has a fall. Staff tried to check temperature and blood pressure (BP), but R1 refused. R1 stated to S1 that R1’s lost her footing and fell down; Tylenol was given to R1. Photos were emailed to LPA with no date stamp of when pictures were taken. Facility staff contacted R1’s responsible party and community directors regarding the incident and an Lic624 was submitted to CCL.

It was alleged that staff did not respond to resident’s request for assistance in a timely manner. Based on interviews, and record review conducted, resident received assistance in a timely manner by pressing the PHB (Call button) which alerted staff members that the resident needed assistance. A PHB call button log was received and reviewed; resident was assisted within 10 minutes by care staff.

It was alleged that staff did not seek medical attention for resident in a timely manner. Based on record review and interviews conducted, staff did seek medical attention for resident in a timely manner. Staff called royal ambulance for R1 to be taken to the hospital after R1 was experiencing left arm pain on 12/24/2019 due to the fall resident sustained on 12/19/2019. Staff informed R1’s daughter that royal ambulance was called. Staff was advised to also call 911 for resident. LPA received and reviewed discharge papers dated for 12/24/2019, and did not identify any broken bones, breaks, or fractures during visit.

Continued on Lic9099-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20220916125605

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: 11/18/2022

NARRATIVE

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It was alleged that facility retained resident needing a higher level of care. Based on record review and interviews conducted, resident is currently receiving care by wellness nurse due to foot infection that began on 6/27/2021. Wellness nurses continues to monitor foot infection to ensure no further infection occurs. LPA obtained care notes which indicate that care is being given to resident regarding foot infection. Wellness nurse is documenting the care that is being implemented while R2 currently resides in the community; care notes have indicated that care continues to be provided by wellness nurse. Primary care physician (PCP) is in communication with wellness nurse.

It was alleged that staff did not report an incident involving resident to their representative. Based on record review and interviews conducted, R2’s representative was notified about the incident that occurred on 6/15/2021 when R2 had a fall hurting his left elbow. Resident received first aid from facility and 911 was called for R2. R2 was transferred to Fremont hospital; responsible parties were updated accordingly. Both incidents, 12/19/2019 and 6/15/2021 were documented and reported on an Lic624.

Although the allegations 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 areUNSUBSTANTIATED.

Exit interview conducted with ADM and Health and Service Director, with a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

LIC9099 (FAS) - (06/04)

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