075601424-10-7-2025-15-AS-BFOG-DMENV5-20251013104719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601424
Report Date: 10/07/2025
Date Signed: 10/07/2025 02:03:04 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
10/22/2024 and conducted by Evaluator Lori Alexander-Washington

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20241022215724

FACILITY NAME:	AEGIS ASSISTED LIVING OF MORAGA		FACILITY NUMBER:	075601424
ADMINISTRATOR:	MARIA ANGELES STICKA		FACILITY TYPE:	740
ADDRESS:	950 COUNTRY CLUB DRIVE		TELEPHONE:	(925) 377-7900
CITY:	MORAGA	STATE: CA	ZIP CODE:	94556
CAPACITY:	100	CENSUS: 87	DATE:	10/07/2025
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Tianna Henderson, General Manager		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff billed resident for services not being rendered by staff
Staff did not follow resident's care plan (DNR)

INVESTIGATION FINDINGS:

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On 10/07/2025 at 12:55 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with General Manager,Tianna Henderson, to deliver the findings of above allegations. LPA explained the purpose of the visit with the General Manager, Tianna Henderson.

During the investigation LPAs interviewed Staff regarding allegations and obtained the following documents: Staff Registry, Resident Registry, Individualized Services Assessments, Physician's Report, Resident Face Sheet, Billing Invoices (Jan '24 thru Sept '24), and Admission Agreement.

LIC9099-C Continued...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 15-AS-20241022215724

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/07/2025

NARRATIVE

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LIC9099-C (Page 2)

Allegation: Staff billed resident for services not being rendered by staff.
Finding: Unsubstantiated

On 10/30/2024, LPA L. Alexander interviewed Witness (W1). W1 stated that R1’s care plan increased from $15,000.00 to $20,000.00. W1 reported that they were billed for 30 days but only paid for 5 days, at approximately $6,000.00. W1 stated that facility only discussed points but never discussed the money.

On 10/31/2024, LPAs Alexander and Doidge interviewed Staff (S1, S2 and S3). S2 stated that R1’s Individualized Service Assessment dated 03/18/2024 totaled 324 points. S2 reported completing a reassessment on 08/06/2024, which resulted in 447 points. S2 explained that once the assessment is completed, the billing department calculates the rate. S2 stated they contacted W1 via email to discuss the new assessment and requested a care conference, but W1 did not respond. S3 reported that they complete resident billing each month. S3 explained that when a new assessment is completed, they enter the total points into the billing system, which calculates the updated rate. S3 stated that they attempted to explain the charges to W1 by phone, but W1 became upset and disconnected the call. S3 further reported that the Responsible Party (RP) removed R1 from the facility on 08/26/2024. S3 also stated: The August billing statement dated 07/18/2024 totaled $15,498.76. A new assessment completed on 08/22/2024 changed the rate to $353.13 per day. This rate applied to the period 08/22/2024 through 09/30/2024 (40 days). Adjustments were made to the account, resulting in a credit of ($6,654.96).

Based on interviews and records reviewed, the allegation that staff billed the resident for services not being rendered is unsubstantiated.

LIC9099-C Continued...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20241022215724

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/07/2025

NARRATIVE

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LIC9099-C (Page 3)

Allegation: Staff did not follow resident's care plan (DNR).
Finding: Unsubstantiated

On 10/30/2024, LPA Alexander interviewed Witness (W1), who stated that on July 3, 2023, R1 was under hospice care with Suncrest Hospice and had a “Do Not Resuscitate” (DNR) order in effect. W1 stated that an Aegis Moraga night care staff member summoned paramedics rather than contacting the hospice team. W1 reported being contacted by paramedics who stated that R1 had been resuscitated. W1 further stated that a hospice representative also contacted them immediately and expressed concern regarding a breach of protocol by facility staff.

On 10/31/2024, LPAs Alexander and Doidge interviewed Staff (S1, S2 and S4) regarding allegations that CPR (Cardiopulmonary Resuscitation) was rendered to R1, who had a DNR on file, around 07/03/2023. S1 stated they were not aware of this incident and reviewed facility records for any corresponding incident report. S1 stated that no LIC624 (Unusual Incident Report) was found in R1’s file. S2 stated that they were not working at the facility during that time period. S4 was interviewed by phone and stated that if any such incident had occurred, it would have been documented in facility records. S4 stated they do not recall any incident involving R1 that required 911 response or CPR being rendered.

On 11/04/2024, LPA Alexander contacted Suncrest Hospice and spoke with W2. W2 confirmed that R1 was discharged from hospice services on 03/14/2023 and re-admitted on 05/26/2023. W2 stated there were hospice notes dated 07/03/2023 for an assessment but nothing in their records indicating a 911 call or CPR performed by emergency personnel.

LIC9099-C Continued...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20241022215724

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/07/2025

NARRATIVE

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LIC9099-C (Page 4)

LPA reviewed the Moraga-Orinda Fire District “Patient Care Report” dated 07/03/2023, which documented an EMT response to the facility at approximately 2135 hours. The report indicated that R1 experienced a syncope episode, was conscious, awake, and alert upon EMT arrival, and had no medical complaints. The report revealed that R1 declined transport to the hospital, and the EMT contacted R1’s Power of Attorney, who also declined transport.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that staff failed to follow R1’s care plan or disregarded a DNR order. Records reviewed indicate that while emergency medical services were contacted, no resuscitation efforts were performed, and R1 remained stable at the scene.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

An exit interview was conducted. A copy of this report were provided to General Manager, Tianna Henderson.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

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