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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019201063
Report Date: 09/29/2023
Date Signed: 09/29/2023 10:09:51 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
08/22/2023 and conducted by Evaluator Liridon Fici
COMPLAINT CONTROL NUMBER: 15-AS-20230822140553
FACILITY NAME:AEGIS GARDENSFACILITY NUMBER:
019201063
ADMINISTRATOR:POON, EMILYFACILITY TYPE:
740
ADDRESS:36281 FREMONT BLVDTELEPHONE:
(949) 488-2669
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:85CENSUS: 74DATE:
09/29/2023
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Gigi Tamayo, Registered Nurse (RN)TIME COMPLETED:
10:10 AM
ALLEGATION(S):
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Staff did not dispense medication according to doctor's orders.
INVESTIGATION FINDINGS:
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On 9/27/2023, at 1:46 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an initial 10- day complaint investigation visit on the above allegation. LPA was greeted by Gigi Tamayo- Registered Nurse (RN), Angel Lee, Director of operations and explained the purpose of the visit.

During visit, LPA collected the following documents for R1, R2, R3, and R4: Residents roster with contact information, staff roster, Incident reports (June and August 2023), Physicians reports, doctors’ orders (June and August 2023), and Medication administrative record (MAR).

LPA interviewed 4 staff members at 2:36PM.


Continue on Lic9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
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-20230822140553
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: 09/29/2023
NARRATIVE
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Continued from Lic9099...

It was alleged that; Staff did not dispense medication according to doctor's orders. Based on Interviews, and record review conducted, S1, S2, S3, and S4 stated that S4 accidentally grabbed the incorrect eye drop bottle and was about to administer medication to resident on 8/19/2023. Reporting Party (RP) noticed S4 was going to use the incorrect eye drops, and RP stopped S4 before administering the eye drops into R1's eyes. S5 was a witness when RP realized S4 grabbed the incorrect eye drop bottle. The correct eye drops for R1 was grabbed and administered to R1 accordingly. S4 was suspended from the community until the investigation was finished.

On 6/23/2023, a different staff had provided multiple drops into R1's right eye and should have only gotten one drop. LPA conducted record review, which confirmed that S4 made a medication error dated 6/23/2023, which was self reported to CCL.

Based on LPAs interviews which were conducted and record review, 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 RN, and a copy of this report provided along with appeal rights.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230822140553
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: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/30/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 (a)(4) Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...(4) To care, supervision, and services that meet their individual needs...
This requirement is not met as evidenced by:
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Administrator agreed to set a plan to complete monthly medication training and to complete comtentency check lists every month and to submit proof of medication training and comtentency check list to CCL by POC due date.
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Based on interviews and record review, the licensee did not comply with the section cited above by not making sure the physicians order for R1's eye drop medication is being used accordingly. On 6/23/2023, facility staff administered the incorrect amount of eye drops into R1's right eye which poses/posed a immediate health, safety or personal rights risk to persons in care.
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3