019201063-8-30-2023-15-AS-KHOS-CVKT5S-20230911142600

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201063
Report Date: 08/30/2023
Date Signed: 08/30/2023 08:10:26 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
06/08/2023 and conducted by Evaluator Liridon Fici

COMPLAINT CONTROL NUMBER: 15-AS-20230608092900

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: 73	DATE:	08/30/2023
		UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Gigi Tamayo- Registered Nurse (RN)		TIME COMPLETED:	08:20 PM

ALLEGATION(S):

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Due to lack of supervision, resident had multiple falls.
Staff stole residents’ belongings.
Staff did not keep resident’s personal information confidential.
Staff discouraged resident in using pendant frequently.
Due to insufficient staffing, resident was transported to the dining room an hour early.

INVESTIGATION FINDINGS:

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On 8/30/2023 at 5:30 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a complaint investigation visit and to deliver findings on the above allegations. LPA met with Gigi Tamayo, Register nurse (Rn) and explained the purpose of today’s visit.

During the course of the investigation, LPA obtained the following documents: Staff roster with contact information, Physicians report, Incident reports, death report, after visit summary, physicians fax report, Individualized service plan (ISP), property and values form, progress notes (October 2022, December 2022, January 2023, and May 2023).

During today’s visit, LPA interviewed five (5) staff and five (5) residents at 5:36 PM.

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: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

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-20230608092900

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: 08/30/2023

NARRATIVE

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It was alleged that; Due to lack of supervision, resident had multiple falls, and staff stole resident’s belongings. Based on interviews conducted, Rp stated that she believes that it is not the facilities fault for resident having a fall. All 5 staff members stated residents are able to use their pendant to call for staff at any time when a resident is requesting assistance from staff members. Staff members have confirmed with LPA that a safety checks are done by staff to ensure all residents are okay and safe. R1, R2, R4, and R5 stated that their belongings were not missing while in care by staff.

It was alleged that; Staff did not keep resident’s personal information confidential, and Staff discouraged resident in using pendant frequently. Based on interviews conducted, All 5 staff and all 5 residents stated that staff allows residents to push their pendants any time they want without any restriction when a resident needs assistance.

It was alleged that; Due to insufficient staffing, resident was transported to the dining room an hour early. Based on interviews conducted, All 5 staff and all 5 residents stated that staff takes residents to the dining area 20 to 30 minutes prior to mealtime. Staff have also stated some residents enjoy going to the dining area early so resident can watch staff prepare for meals and speak to staff while waiting for their meals. S5 stated staff will knock on the resident’s door as a reminder to go to the dining room.

Based on Interviews 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 are UNSUBSTANTIATED.

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: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC9099 (FAS) - (06/04)

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