015601374-12-30-2022-15-AS-KHOS-CMXN2R-20230110090510

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601374
Report Date: 12/30/2022
Date Signed: 12/30/2022 03:20:36 PM

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-20220916102404

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: 98	DATE:	12/30/2022
		UNANNOUNCED	TIME BEGAN:	02:07 PM
MET WITH:	PAUL H SHEPODD, Administrator		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff do not report resident's change in condition to responsible party.
Staff do not follow resident's physician's order.
Staff do not assist resident with grooming.

INVESTIGATION FINDINGS:

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On 12/30/2022 at approximately 2:07 PM, Licensing Program Analysts (LPAs) Liridon Fici and J. Clancy-Czuleger arrived unannounced to delivery findings on the above allegations. LPAs were greeted by Paul Shepodd, Administrator (ADM), and

During the course of the investigation, LPAs reviewed and obtained documents of the following, incident reports, physician report, physician orders, progress notes, ADL service delivery record, Individual service plan (ISP) and performed 4 of 4 interviews with community staff, and health service director.

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: 12/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2022

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-20220916102404

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: 12/30/2022

NARRATIVE

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Continued from Lic9099

It was alleged that, staff do not report resident's change in condition to responsible party. Based on record review and interviews conducted, R1’s family was notified on 6/27/2021 when R1’s foot infection began. Wellness nurse documented foot infection on care notes and the process of the infection. Wound care began on 6/27/2021 and has been implemented by wellness nurse and continues to receive wound treatment by nurse in the community. Needs/service plan dated for 10/26/2022 states R1 is at increased risk for skin breakdown and for staff to conduct routine checks for new skin issues and to report to nurse. R1’s foot infection is on-going and is being cared for and documented by community wellness nurse.

It was alleged that, staff do not follow resident's physician's order. Based on record review and interviews conducted, progress notes stated on 6/27/2021, R1’s foot infection began, and physicians’ orders was received for R1’s foot infection for wound treatment. Wound care was being carried out by wellness nurse starting on 6/27/2021 and continued to follow Physicians order. On 7/30/2021, a new physicians order was placed for R1’s foot swelling due to leg infection. On 9/12/2022, a new order was received for leg infection and were followed; Orders by the physicians were carried out until further notice and has been documented in progress notes.

It was alleged that staff, do not assist resident with grooming. Based on record review and interviews conducted, wellness nurse have performed ADLs to include grooming for R1 on a daily basis dated June 2022- October 2022. LPA received R1’s ADLs service delivery records that indicates ADLs were performed by staff. R1’s ISP has also indicated that ADLs including grooming are to be performed twice a day by staff.

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 allegation are UNSUBSTANTIATED.

Exit interview conducted with ADM, and 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: 12/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2022

LIC9099 (FAS) - (06/04)

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