<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601424
Report Date: 01/28/2021
Date Signed: 01/28/2021 02:49:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AEGIS ASSISTED LIVING OF MORAGAFACILITY NUMBER:
075601424
ADMINISTRATOR:PHELPS, WILLIAMFACILITY TYPE:
740
ADDRESS:950 COUNTRY CLUB DRIVETELEPHONE:
(925) 377-7900
CITY:MORAGASTATE: CAZIP CODE:
94556
CAPACITY:100CENSUS: 67DATE:
01/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Blanca Hurtado, Nurse DirectorTIME COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 01/28/21 at 1:10PM, LPA D Panlilio conducted a case management tele-visit with Health Services Director (S1) to discuss the incident reported to CCLD on 01/15/21 wherein a staff in Med Tech training (S2) switched 14 tablets of Norco for ibuprofen 800 mg. on 01/10/21. Due to COVID-19 shelter in place order, S1 was not physically available to sign this report.

S1 stated that S2 was hired on 12/30/20 as an on call Med Tech in training program. On coming NOC medication care manager (S4) noted the change in tablet size and reported the incident to the Health Services Director (S1).Facility conducted an internal investigation and interviewed staff responsible for counting and dispensing of centrally stored and controlled scheduled medications.

Per Hiring Director (S3), S2 was removed from the medication assistance program on 01/10. She left the facility the same day and has not returned since. Per S3, if S2 does not show up for work in 2 weeks, they will proceed with termination. Medication caregivers and Wellness nurses underwent a refresher course on procedures and policies for Centrally stored medication, Controlled scheduled medication protocol and medication key cart control policies on 01/12/21. Med care managers were also written up for not following procedures on medication administration.

No deficiencies observed or cited during this tele- visit. Exit interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1