019201063-8-23-2023-15-AS-KHOS-CVCQUV-20230904122923

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201063
Report Date: 08/23/2023
Date Signed: 08/23/2023 04:33:30 PM

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
08/22/2023 and conducted by Evaluator Liridon Fici

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230822140553

FACILITY NAME:	AEGIS GARDENS		FACILITY NUMBER:	019201063
ADMINISTRATOR:	POON, EMILY		FACILITY TYPE:	740
ADDRESS:	36281 FREMONT BLVD		TELEPHONE:	(949) 488-2669
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	85	CENSUS: 74	DATE:	08/23/2023
		UNANNOUNCED	TIME BEGAN:	01:46 PM
MET WITH:	Gigi Tamayo, RN, and Angel Lee, Director of operations		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Staff did not dispense medication according to doctor's orders.

INVESTIGATION FINDINGS:

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On 8/23/2023, at 1:46 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an initial 10-day complaint investigation visit and to deliver findings on the above allegation. LPA was greeted by Gigi Tamayo- Registered Nurse (RN), Angel Lee, Director of operations and explained the purpose of the visit.

During visit, LPA collected the following documents for R1, R2, R3, and R4: Residents roster, staff roster with contact information, Incident reports (June and August 2023), Physicians reports, doctors’ orders (June and August 2023), and Medication administrative record (MAR).

LPA interviewed 4 staff members at 2:36PM.

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: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

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-20230822140553

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 GARDENS	FACILITY NUMBER: 019201063
	VISIT DATE: 08/23/2023

NARRATIVE

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It was alleged that; Staff did not dispense medication according to doctor's orders. Based on Interviews conducted, S1, S2, S3, and S4 stated that S4 accidentally grabbed the incorrect eye drop bottle and did not administer the eye drop medication to the resident on 8/19/2023. S4 and S5 both realized that the eye drop medication that was grabbed was not the correct eye drops and S4 grabbed the correct eye drop bottle and administered the eye drops to the residents’ eyes. S4 was suspended from the community until further notice.

Based on Interviews conducted, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during visit

Exit interview conducted with RN, 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: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC9099 (FAS) - (06/04)

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