075601424-11-10-2022-15-AS-KHOS-CLULUU-20221206080432

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601424
Report Date: 11/10/2022
Date Signed: 11/10/2022 02:26:44 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
05/26/2022 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220526114437

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: 63	DATE:	11/10/2022
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Angeles Sticka, General Manager		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Staff are not provided PPE
Residents are being left in soiled diapers
Residents are not being showered timely
Residents are falling due to insufficient staffing

INVESTIGATION FINDINGS:

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On 11/10/2022 at 9:10 a.m., Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegations and respect to deliver investigation findings. LPA met with General Manager (GM) and explained the purpose of the visit.

Allegation: Staff are not provided PPE – Unsubstantiated.
The Department has investigated this allegation and per records review and interviews and found that 6 staff (S2, S3, S4, S5, S6, and S7) who were interviewed stated that PPE were provided to staff at work.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220526114437

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: 11/10/2022

NARRATIVE

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Allegation: Residents are being left in soiled diapers – Unsubstantiated.
The Department has investigated this allegation and per records review and interviews and found that no resident was identified being left in soiled diapers. 6 residents (R3, R5, R6, R7, R9, and R10) and 2 witnesses (W1 and W4) stated that residents were assisted with changing diapers as needed.

Allegation: Residents are not being showered timely – Unsubstantiated.
The Department has investigated this allegation and per records review and interviews and found that residents on shower schedules were assisted with showering on time. 5 residents (R3, R5, R6, R7 and R10) and 1 witness (W4) stated that residents got showers 2-3 times per week.

Allegation: Residents are falling due to insufficient staffing – Unsubstantiated.
The Department has investigated this allegation and per records review and interviews and found that 2 residents (R1 and R2) were reported unwitnessed fall in subject time period, R1 didn’t remember fall had happened. R2 was not alert, R2’s family member W2 stated that R2 has been cared well by staff and has not observed staffing shortage issue. No additional information is obtained to allege falling due to insufficient staffing. 5 residents (R5, R6, R7 R9 and R10) and 1 witnessed (W1) stated that staff showed up as quickly as within 5-10 minutes when residents pressed their call button.

Based on observation, records reviewed, and interview conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

No deficiency cited, exit interview conducted with GM, and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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