015601374-7-19-2023-15-AS-KHOS-CU9MH3-20230731093651

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601374
Report Date: 07/19/2023
Date Signed: 07/19/2023 10:56:19 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
01/19/2023 and conducted by Evaluator Liridon Fici

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230119160210

FACILITY NAME:	AEGIS ASSISTED LIVING OF FREMONT		FACILITY NUMBER:	015601374
ADMINISTRATOR:	PAUL H SHEPODD		FACILITY TYPE:	740
ADDRESS:	3850 WALNUT AVENUE		TELEPHONE:	(510) 739-1515
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	110	CENSUS: 80	DATE:	07/19/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Shashi Madahar, Administrator		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident hospitalized due to neglect.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 7/19/2023 , at 9:45 AM, Licensing Program Analyst (LPAs) L. Fici arrived unannounced to conduct a subsequent complaint investigation visit and to deliver findings on the above allegation. LPA were greeted by Shashi Madahar, Administrator (ADM) and explained the purpose of the visit.

During visit, LPA interviewed Three (3) of Five (5) residents at 9:53 AM

During the course of the investigation, LPA interviewed 6 of 6 staff members. LPA obtained the following documents: Staff & resident roster, Staff contact information, physician reports, Individualized service plan, incident reports (January 2023), progress notes, pre-appraisals, discharge notes, doctors’ notes, food menu, and residents weight record sheets of a sample of 6 of 6 residents.

It was alleged that; resident was hospitalized due to neglect. Based record review and interviews conducted, all six (6) staff members elaborated the community’s protocol when a resident is not eating and drinking enough such as, checking vital signs in residents, reenforcing resident to consume foods and drink more liquids, and to fill out a change of condition and to submit to wellness nurse. All 6 staff members also explained the necessary actions to take when a resident needs medical attention. A charge of condition form is submitted to the community’s wellness nurse by staff that indicates the resident’s current health concern. All 6 staff members elaborated on further evaluation when a resident’s health is declining. LPA reviewed progress notes in detail printed on January 27, 2023, for R1, which indicated staff monitoring resident on a day-by-day basis. On 1/16/2023, resident was admitted into the hospital and on 2/3/2023, resident returned to the community from the hospital.

Continue on Lic9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

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 2

Control Number 15-AS-20230119160210

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AEGIS ASSISTED LIVING OF FREMONT	FACILITY NUMBER: 015601374
	VISIT DATE: 07/19/2023

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 26 27 28 29 30 31 32	Continued from Lic9099 Based on Interviews and record review conducted, 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 is UNSUBSTANTIATED. Exit interview conducted with ADM, and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2