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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601424
Report Date: 08/11/2022
Date Signed: 08/11/2022 01:21:40 PM


Document Has Been Signed on 08/11/2022 01:21 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:AEGIS ASSISTED LIVING OF MORAGAFACILITY NUMBER:
075601424
ADMINISTRATOR:RICHARD PIELSTICKFACILITY TYPE:
740
ADDRESS:950 COUNTRY CLUB DRIVETELEPHONE:
(925) 377-7900
CITY:MORAGASTATE: CAZIP CODE:
94556
CAPACITY:100CENSUS: DATE:
08/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Wonsuk Choi, Business ManagerTIME COMPLETED:
01:30 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 08/11/22 at 11:35 AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving 2 self-reported incidents submitted to CCLD regarding mediation error. LPA explained the purpose of the visit with business manager, General Manager Angeles Sticka arrived at a later time.

Based on records review, the following incident reports were submitted to CCL:
On 4/28/2022, facility self-reported administered wrong dosage of medication Lorazepam to resident (R1) at 7:20am on 4/20/2022. R1 was not resulted injury or medical problem due to this incident. In-service training was provided to staff (S1) on 4/21/2022.

On 7/12/2022, facility self-reported administered wrong dosage of medication Hydrocodone to resident (R2) at 5:00pm on 7/10/2022. R2 was not resulted injury or medical problem due to this incident. In-service training was provided to staff (S2) on 7/17/2022.

On 8/1/2022, LPA advised LVN (S3) to retrain all med-tech. S3 submitted proof of training to CCL on 8/4/2022.


Due to medication error occurred twice in 90 days, deficiency is cited per Title 22 California Code of Regulations and listed on LIC809-D. Failure to submit proofs of correction (POC) by plan of correction due date and/or repeat deficiency within a 12-month period may result in civil penalties.

Exit interview conducted with General Manager. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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 2


Document Has Been Signed on 08/11/2022 01:21 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
E BAY DELTA AC/SC, 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: 08/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2022
Section Cited

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care
(a)...The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(5) Facility staff, except those authorized by law..Assistance with self-administered medications shall be limited to the following:
(A) Medications usually prescribed for self-administration which have been authorized by the person's physician.
This requirement is not met as evidenced by…
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited above. Medication error incidents occurred twice in 90 days which poses a potential health and safety concern to persons in care.

8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2