019201063-6-6-2023-15-AS-KHOS-CSQGTK-20230612053739

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201063
Report Date: 06/06/2023
Date Signed: 06/06/2023 04:45:34 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/01/2023 and conducted by Evaluator Liridon Fici

COMPLAINT CONTROL NUMBER: 15-AS-20230601140155

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:	06/06/2023
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Gigi Tamayo, RN		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff mismanaged resident's medications.
Staff overmedicated resident.

INVESTIGATION FINDINGS:

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On 6/6/2023, at 12:05 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an initial 10- day complaint investigation visit and to deliver complaint findings on the above allegations. LPA was greeted by Gigi Tamayo- Registered Nurse (RN) and explained the purpose of the visit.

During the visit, LPA interviewed one (1) resident, and two (2) staff members. LPA obtained the following documents: Staff & resident roster, current staff medication training log, Staffs medication error statement, Physicians report, Incident reports (May 2023), Progress notes (May 2023), and medication administrative record (MAR).

Continue on Lic9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

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-20230601140155

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AEGIS GARDENS	FACILITY NUMBER: 019201063
	VISIT DATE: 06/06/2023

NARRATIVE

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Continued from Lic9099

It was alleged that, staff mismanaged resident’s medications, and staff over-medicated resident. Based on interviews and record review conducted, S1 confirmed with LPA that S2 mistakenly gave R1 eleven (11) types of oral medications from another resident in care on 5/28/2023. While interviewing S2, S2 confirmed with LPA that she mistakenly gave 11 types of oral medications to R1 on 5/28/2023 at approximately 8:15 AM. S1 submitted an incident report regarding medication error on 5/29/2023.

LPA reviewed discharge notes for R1, which indicates that R1 had a medication overdose due to taking incorrect medication. LPA reviewed incident reports, progress notes and staff medication error statement from S2 and S3 which indicated that R1 was given the wrong medication and R1 had a medication overdose on 5/28/2023. Facility staff called 911 for further evaluation, and R1 was admitted to the hospital and returned to the facility the next day 5/29/2023, at approximately 5:30 PM.

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, appeal rights given along with a copy of this report.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230601140155

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AEGIS GARDENS	FACILITY NUMBER: 019201063
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/07/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements - General:(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to submit a plan to LPA to conduct additional medication in-service training with a skilled nurse and to have training signed by all med techs and to submit proof of signed in-service training to CCL by POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above by not giving R1 the correct medications and mistakenly giving R1 another residents medication which posed a immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type A 06/07/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465(c)(2) Incidental Medical and Dental Care: (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above by overmedicating R1 with incorrect medication that did not belong to R1 which posed a immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	Administrator agreed to submit a plan to LPA to write a self-certifcation on section 87465(c)(2)-Incidental Medical and Dental Care and to have all med techs read, understand, and have it signed and to submit a copy of the signed self-certifcation to CCL by POC due date.

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC9099 (FAS) - (06/04)

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