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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601424
Report Date: 09/26/2024
Date Signed: 09/26/2024 12:19:36 PM


Document Has Been Signed on 09/26/2024 12:19 PM - It Cannot Be Edited

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:MARIA ANGELES STICKAFACILITY TYPE:
740
ADDRESS:950 COUNTRY CLUB DRIVETELEPHONE:
(925) 377-7900
CITY:MORAGASTATE: CAZIP CODE:
94556
CAPACITY:100CENSUS: 61DATE:
09/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Angeles Sticka General ManagerTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) D. Doidge and C. Fowler arrived unannounced to conduct a case management visit in response to the Unusual Incident Report (UIR) for three residents (R1, R2 and R3), that AWOLed, submitted by the facility to the Department. LPAs met with and informed, Angeles Sticka, General Manager, of the purpose of visit.

UIR received indicated on September 14. 2024, R1, R2 and R3 AWOLed from facility by opening an alarmed side gate from the memory care's courtyard and walked out. R2 pushed on the door until it opened, R1 and R3 followed. R2 headed left toward the front of the facility and was found by staff in front of the facility. R2 and R3 had walked straight out and were later found a few blocks away by the police.

LPAs reviewed of Physician's Report for all three residence that showed dementia and unable to leave the facility unassisted.

LPAs toured the facility, observed auditory signals on outer gates for the memory care courtyard.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights, were provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/26/2024 12:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 ASSISTED LIVING OF MORAGA
FACILITY NUMBER: 075601424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2024
Section Cited
CCR
87468.2

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(a) In addition to the rights listed in Section 87468.1, .residents...for the elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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By POC date, General Manager agreed to conduct extra training on alarm response with all staff and provide list of attendees for training to CCLD.
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This requirement is not met as evidence by: based on record review, residence R! R2 and R3 are not able to leave facility unassisted due to diagnosis. Residence AWOLed due to lack of supervision and timely response to alarms.
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CCR

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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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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