019201063-10-6-2023-15-AS-KHOS-CWPK9V-20231017074300

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201063
Report Date: 10/06/2023
Date Signed: 10/06/2023 10:52:48 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
07/18/2023 and conducted by Evaluator Liridon Fici

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230718160825

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:	09:55 AM
MET WITH:	Angel Lee, Director of Operations		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Illegal Eviction.

INVESTIGATION FINDINGS:

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On 10/6/2023 at 9:55 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 three (3) staff members. 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 June/July 2023), and eviction letter 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-20230718160825

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, an illegal eviction was given to the resident and the resident’s representative. Based on interviews and record reviews conducted, all 3 staff stated if a resident’s level of care increases and the facility can not meet the care needs for the resident any longer, an eviction notice is given to the resident and the resident's representative explaining the reason for eviction. The facility determined R1’s change of condition by ongoing evaluation for R1 and conducting reappraisals which informs the facility of R1’s higher level of care on June 7, 2023. On July 8, 2022, R1 was admitted into Aegis gardens and an appraisal was conducted. The facility was able to meet R1’s care needs, however, over the course of time, R1’s care needs increased, and the facility was not able to meet R1’s care needs. The facility conducted re-appraisals for R1 when R1’s care increased.

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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