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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601424
Report Date: 11/10/2022
Date Signed: 11/10/2022 02:28:37 PM


Document Has Been Signed on 11/10/2022 02:28 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:MARIA ANGELES STICKAFACILITY TYPE:
740
ADDRESS:950 COUNTRY CLUB DRIVETELEPHONE:
(925) 377-7900
CITY:MORAGASTATE: CAZIP CODE:
94556
CAPACITY:100CENSUS: 63DATE:
11/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:23 PM
MET WITH:Angeles Sticka, General ManagerTIME COMPLETED:
02:40 PM
NARRATIVE
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On this day 11/10/22, Licensing Program Analyst (LPA) C. Lin conducted a case management visit and met with General Manager (GM). LPA explained to GM the purpose of the visit.

During an investigation conducted by the Department on 6/3/2022, the following deficiencies were observed

· Staff S6 did not wear full PPE while providing care to Covid-19 positive resident. LPA and former Administrator (S1) observed that S6 walked out from an isolation room 104 with surgical mask and gloves only, and S6 didn’t perform PPE donning and doffing properly.

· Staff S2 admitted that “Staff are working crossover for both Covid-19 positive and negative residents due to staff shortage”. S2 stated that it was permitted by the Contra Costa Public Health (W3). LPA contacted W3, W3 stated that S2 was instructed to designate staff for Covid-19 positive residents only, staff was not allowed crossover working between positive and negative residents.

Continue on LIC809-C

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
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 4


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
VISIT DATE: 11/10/2022
NARRATIVE
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In addition, facility self-reported an incident regarding medication error to resident (R1) and submitted incident report (LIC624) to CCL on 11/4/2022. It’s a repeating violation within 12-months, a $250 civil penalty is assessed today.

The above deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalty.



Exit interview conducted with GM. A copy of this report and Appeal Rights were provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/10/2022 02:28 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: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2022
Section Cited

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87470 Infection Control Requirements
(b)...residents in the facility are diagnosed with a communicable disease, the following shall apply:
(2) All staff and volunteers...shall wear appropriate Personal Protective Equipment (PPE) to prevent....
This requirement is not met as evidenced by…
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Based on observation the licensee did not comply with the section cited above. LPA observed staff did not wear full PPE while providing care to Covid-19 positive resident which poses a potential health, safety or personal rights risk to persons in care.
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Type B
11/17/2022
Section Cited

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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful...
This requirement is not met as evidenced by…
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Based on observation the licensee did not comply with the section cited above. LPA observed staff crossover working between Covid-19 positive and negative residents which poses a potential health, safety or personal rights risk to persons in care.
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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) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 11/10/2022 02:28 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: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2022
Section Cited

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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…
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Based on record review, the licensee did not comply with the section cited above. Medication error incident occurred to resident on 11/2/2022 which poses a potential health and safety concern to persons in care.
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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) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4