019201063-8-24-2023-15-AS-KHOS-CVKLV2-20230911090449

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201063
Report Date: 08/24/2023
Date Signed: 08/24/2023 05:32:01 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
08/17/2023 and conducted by Evaluator Liridon Fici

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230817132333

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:	08/24/2023
		UNANNOUNCED	TIME BEGAN:	01:46 PM
MET WITH:	Gigi Tamayo, Registered Nurse (RN)		TIME COMPLETED:	05:40 PM

ALLEGATION(S):

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Staff charged residents for services not received.

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) and explained the purpose of the visit.

During visit, LPA reviewed the following documents: Residents roster, Identification and Emergency Information (Lic601), Admissions agreement, Statement billing log, Aegis gardens contract, and Needs and service plan of a sample of 6 of 6 residents in care.

LPA interview S1, S2, and S3 at 3:36 PM, and representatives of R1, R2, R3, R4, R5, and R6 at 4:45 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: 08/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023

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-20230817132333

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: 08/24/2023

NARRATIVE

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It was alleged that, Staff charged residents for services not received. Based on interviews and record review conducted, S1, S2, and S3 stated that tray service was complimentary during the time when the facility had a Covid-19 outbreak, and no residents were charged. All three staff stated tray service is the only service that is complimentary during a Covid-19 outbreak. LPA confirmed with S1, S2, and S3 that if tray service was charged, a refund is granted back to the residents’ representative. LPA interviewed and spoke to R1- R6’s representatives, and they have all stated that were was no extra charge made by Aegis Gardens for tray services during COVID-19 outbreak. In addition, R1-R6 were not charged for escorting and eating supervision during the time of Covid-19 outbreak dated for October 16 - November 17, 2022, January 01-23, 2023, and February 06-16, 2023. LPA reviewed residents’ statement invoices which indicated there were no extra service charges made to the residents’ representatives by Aegis Gardens.

Based on Interviews and record review 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.

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: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC9099 (FAS) - (06/04)

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