019201063-10-6-2023-15-AS-KHOS-CWPLJM-20231017084809

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201063
Report Date: 10/06/2023
Date Signed: 10/06/2023 10:52:26 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
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:	09:45 AM
MET WITH:	Angel Lee, Director of Operations		TIME COMPLETED:	09:55 AM

ALLEGATION(S):

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Staff did not treat residents with dignity and respect.
Staff did not include resident's responsible party in the reappraisal process.
Facility is charging resident for services not agreed upon.

INVESTIGATION FINDINGS:

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On 10/6/2023 at 9:45 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

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: 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)

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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

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It was alleged that, Staff did not treat residents with dignity and respect and staff did not include resident's responsible party in the reappraisal process. Based on interviews and record review conducted. All 5 staff stated that the care given to residents is good and that the staff tends to residents’ care needs at all times. Residents are treated with respect and cared for when residents needs assistance with anything. 4 of the 5 residents interviewed stated that they do not have any concerns with care and that they are treated well in the community. During record review, LPA communicated with S1 and confirmed that there was a re-appraisal conducted for R1 and R1's representative was notified.

It was alleged that, Facility is charging resident for services not agreed upon. Based on interviews and record reviews conducted, family staff communicated with LPA and confirmed that RP was notified regarding R1's level of care is increasing, and that the facility wants to hold a meeting to further speak about R1’s care. Staff stated that R1 is in need for a one on one due to resident’s higher level of care.

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 is UNSUBSTANTIATED.

Exit interview conducted with Director of Operations, 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: 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)

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