019201063-2-15-2024-15-AS-KHOS-CVSJBW-20230918065502

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201063
Report Date: 08/30/2023
Date Signed: 02/15/2024 10:44:37 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
06/13/2023 and conducted by Evaluator Liridon Fici

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230613151024

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: 73	DATE:	08/30/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Gigi Tamayo- Registered Nurse (RN)		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Facility staff did not seek medical attention for resident in a timely manner.

INVESTIGATION FINDINGS:

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On 2/15/2024 at 10:10am, Licensing Program Analysts (LPAs), L. Hall and T. Syess-Gibson arrived unannounced to redeliver complaint findings for the above allegation. LPAs met with Angel Lee, Director of Operations, and explained the purpose of the visit. Gigi Tamayo, Health Services Director arrived at 10:30am.

During the course of the investigation, LPA L. Fici interviewed four (4) staff members, five (5) residents, Reporting Party (RP), obtained and reviewed the following documents: staff roster, resident roster, the physician’s report, incident reports, progress notes, medication administrative record (MAR), and communication documents between the facility and the physician for R1.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

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-20230613151024

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: 08/30/2023

NARRATIVE

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The department received additional information from RP and all documents, and the interviews conducted by former LPA, L. Fici, was re-reviewed by LPA, L. Hall. LPA met with and delivered the amended report.

Allegation: Staff did not seek medical attention for a resident in a timely manner.

The RP stated it took the staff approximately 45 minutes to contact 9-1-1 for resident (R1). Based on interviews and record review, including 2 incident reports, R1 was given the wrong medication (belonging to another resident) around 8:00am on May 28, 2023. The staff (S1) notified S4 (registered nurse) around 9:24am of the error, this was the time S1 had realized the mistake had occurred. S4 immediately conducted an assessment with R1, including taking vitals in the presence of R1’s family. The vitals were stable and R4 informed R1’s doctor via fax of the error. Around 10:15 am R1 was observed to be ‘sleepy’ and vitals were rechecked and observed to have changed. At this time, 9-1-1 call was immediately made and R1 was transported to Kaiser Hospital. R1 was discharged back to the facility on May 29, 2023.

Based on record review of communication between the facility and the physician. It indicates that the facility had sent notification to the physician at 10:07am on May 28, 2023, that contained the medication that was taken and R1’s vitals that were taken when S4 was first notified. The physician replied on May 30, 2023, that R1 had been seen in the emergency department.

Review of previous complaint dated June 1, 2023, control #15-AS-20230601140155, the Health Service Director (HSD) submitted a plan that will provide training in medication errors, assess the medication assistance process, and make the necessary changes to prevent errors. The Health Service Director also will enforce documentation standards for medication policy per the plan submitted to Community Care Licensing Department.

Based on Interviews 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: Laura Hall	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

LIC9099 (FAS) - (06/04)

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