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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201060
Report Date: 07/25/2024
Date Signed: 07/25/2024 07:11:18 PM


Document Has Been Signed on 07/25/2024 07:11 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 LIVING PLEASANT HILLFACILITY NUMBER:
079201060
ADMINISTRATOR:LINDA L. FISHERFACILITY TYPE:
740
ADDRESS:1660 OAK PARK BLVDTELEPHONE:
(925) 939-2700
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:90CENSUS: 73DATE:
07/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Yelba Havelhorst, Care DirectorTIME COMPLETED:
07:30 PM
NARRATIVE
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On 07/25/2024 at 2:50 PM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 05/30/2024. LPA met with Care Director, Yelba Havelhorst and Health Services Director, Davinderjit Singh and explained the purpose of the visit.

CCL received an Unusual Incident Report that reported that Resident (R1) eloped from the facility on 05/26/2024 at around 7:15 AM. Staff (S1) stated that the morning shift observed R1 sitting on the front chair near the concierge area. S1 stated that they think R1 left when the morning staff was coming inside the front door. S1 stated that R1 has 2 (two) daughters that live out-of- state and the daughters check the GPS that is located on R1's watch. S1 stated that the Med Tech was looking for R1 at around 8:00 AM to give him his morning medication but he was not in his room. S1 stated that the staff were looking for R1 inside and outside the building.

S1 stated that security from San Francisco International Airport (SFO) called and spoke to the facility's concierge and indicated that they found a person that matched the description. S1 stated that R1's daughters checked the GPS and that is when they discovered that R1 was at SFO. S1 stated that the daughters called SFO security and gave a description of R1. S1 stated that a friend of R1's ex-wife was the person that went to SFO to pick up R1 and brought R1 back to the facility. S1 stated that the facility did not know that R1 was missing until SFO security called them.

LIC809-C Continued...
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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 LIVING PLEASANT HILL
FACILITY NUMBER: 079201060
VISIT DATE: 07/25/2024
NARRATIVE
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LIC809-C Continued...

LPA obtained the following documents:

Physician's Report, Residence and Care Agreement, Progress Notes, Two Hour Check, Resident Emergency Information Form, Physician's Orders, Individualized Service Assessment, Individualized Service Plan (06/13/24 and 07/09/24), Sign-out sheet and Aegis Living Elopement Response Protocol.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 07/25/2024 07:11 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 LIVING PLEASANT HILL
FACILITY NUMBER: 079201060

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2024
Section Cited
CCR
87211(a)(2)

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(2) Occurrences...which threaten the welfare, safety or health of residents,...shall be reported within 24 hours...

This requirement was not met as evidence by:
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By POC date, Licensee will submit to CCLD a detailed written plan on how they will address reporting incidents, including but not limited to AWOL.
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Based on observation,interview, and review the licensee did not comply with the section cited above by not reporting to CCL within 24hrs which posed a potential health, safety or personal rights risk to persons in care.
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Type B
08/01/2024
Section Cited
CCR87468.2(a)(4)

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To care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency...

This requirement was not met as evidence by:
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By POC date, Licensee will submit to CCLD a detailed written plan on how they will address incidents of elopement and safety including but not limited to AWOL.
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Based on interview, the licensee did not comply with the section cited above by S1 stated that resident did not have "Wander Guard" on which posed a potential health and safety 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) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 07/25/2024 07:11 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 LIVING PLEASANT HILL
FACILITY NUMBER: 079201060

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2024
Section Cited
CCR
87705(b)(2)

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In addition to the requirements..., the plan of operation shall...needs of residents with dementia, including: (2) Safety measures... such as wandering, aggressive behavior...

This requirement was not met as evidence by:
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By POC date, Licensee will submit to CCLD a detailed written plan on how they plan to mitigate residents that elope from the facility and what actions the facility will take, including but not limited to AWOL.
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Based on observation, interview and review the licensee did not comply with the section cited above by the agency determined that staff did not know the resident exited the facility which posed a potential health and safety 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) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4