075601424-4-4-2022-15-AS-KHOS-CDLKCM-20220418074721

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601424
Report Date: 04/04/2022
Date Signed: 04/04/2022 06:26:24 PM

Unsubstantiated

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
01/03/2022 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220103090654

FACILITY NAME:	AEGIS ASSISTED LIVING OF MORAGA		FACILITY NUMBER:	075601424
ADMINISTRATOR:	RICHARD PIELSTICK		FACILITY TYPE:	740
ADDRESS:	950 COUNTRY CLUB DRIVE		TELEPHONE:	(925) 377-7900
CITY:	MORAGA	STATE: CA	ZIP CODE:	94556
CAPACITY:	100	CENSUS: 65	DATE:	04/04/2022
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Won Suk Choi, Business Office Manager		TIME COMPLETED:	06:40 PM

ALLEGATION(S):

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Staff left resident's in soiled clothing for extended period of time.
Staff are not providing adequate food service for resident's.
Facility is not clean.

INVESTIGATION FINDINGS:

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On 4/4/22 at 9:25am, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegations and deliver investigation findings. LPA explained the purpose of the visit to the Business Office Manager, Won Suk Choi.

Allegation: Staff left resident's in soiled clothing for extended period of time– Unsubstantiated
The Department has investigated this allegation and per interviews and records review, 2 residents stated that soiled clothing for extended period of time has not happened to them. 2 out of 13 staff stated that soiled clothing was observed from the previous shift because staff shift was ended then would tell the next shift staff to take care of it, and it would be taken care in a time manner.

Continue on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

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-20220103090654

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 ASSISTED LIVING OF MORAGA	FACILITY NUMBER: 075601424
	VISIT DATE: 04/04/2022

NARRATIVE

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Allegation: Staff are not providing adequate food service for resident's– Unsubstantiated

The Department has investigated this allegation and per interviews, records review, and observations, 2 residents stated that food was served in nice and warm, 6 out of 7 caregivers stated that food was served in warm. 2 caregivers stated that food could become cold if residents couldn’t finish it in short period of time, caregivers microwaved it sometimes. 6 out of 7 caregivers stated that forcing residents to eat was not observed or witnessed. Sufficient food was observed in the kitchen during visit.

Allegation: Facility is not clean– Unsubstantiated

The Department has investigated this allegation and per interviews, records review and observations, facility was observed clean and has no smell during visit. 6 out of 7 caregivers stated that they have been instructed and trained to maintain facility clean, they cleaned up residents’ mess as needed when housekeeper was not scheduled.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited. Exit interview conducted with Business Office Manager, and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

LIC9099 (FAS) - (06/04)

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