019201063-10-6-2023-15-AS-KHOS-CWPLJL-20231017084808

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201063
Report Date: 10/06/2023
Date Signed: 10/06/2023 10:51:29 AM

Substantiated

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
07/12/2023 and conducted by Evaluator Liridon Fici

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230712154204

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: 98	DATE:	10/06/2023
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Angel Lee, Director of Operations		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff improperly administered resident's medication.

INVESTIGATION FINDINGS:

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

On 10/6/2023 at 9:35 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an subsequent complaint investigation visit and to deliver findings on the above allegation. LPA was greeted by Angel Lee, Director of Operations and explained the purpose of the visit.

During the course of the investigation, LPA interviewed five (5) staff members and five (5) residents. LPA requested and obtained the following documents: Staff roster with Contact information, residents’ roster, Admission agreement, Physicians reports, Individualized service plan (ISP), Individualized service assessment (ISA), progress notes (July 2022), and Medication administration record (MAR) of a sample of 5 of 5 residents.

Continue on Lic9099-C

Substantiated

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: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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 3

Control Number 15-AS-20230712154204

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: 10/06/2023

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

Continue from Lic9099

It was alleged that, Staff improperly administered resident's medication. Based on record review conducted, LPA communicated with RP and it was confirmed that R1’s medication was crushed and given to R1 without a physician’s order on July 8, 2023. On July 11, 2023, a request was sent to the primary physician to crush medication for R1 and on July 12, 2023, R1’s physician approved request to crush medication for R1.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D

Exit interview conducted with Director of Operations, and a copy of this report provided along with appeal rights.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20230712154204

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/07/2023 Section Cited CCR 87465(e)	1 2 3 4 5 6 7	87465(e) Incidental Medical and Dental Care:(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to submit a self-certification on section 87465(e) Incidental Medical and Dental Care by explaining how will this be avoided in the furture and to understand the reguation. All med techs, administrators, health service directors, nurses, and care directors will date and sign self-certification and submit to CCL by POC due date.
	8 9 10 11 12 13 14	Based on observation, and record review, the licensee did not comply with the section cited above by crushing R1's medication prior to submitting a physicians order to R1's primary physicians to crush medication which poses/posed a immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3