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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201060
Report Date: 11/07/2024
Date Signed: 11/07/2024 06:50:23 PM

Document Has Been Signed on 11/07/2024 06:50 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/
DIRECTOR:
LINDA L. FISHERFACILITY TYPE:
740
ADDRESS:1660 OAK PARK BLVDTELEPHONE:
(925) 939-2700
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY: 90CENSUS: 76DATE:
11/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:10 PM
MET WITH:Linda L. Fisher, General ManagerTIME VISIT/
INSPECTION COMPLETED:
07:15 PM
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On 11/07/2024 at 5:10 PM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to Community Care Licensing Division (CCLD) on 10/01/2024. LPA met with General Manager, Linda L. Fisher and explained the purpose of the visit. GM, Linda L. Fisher, had to leave and authorized Health Services Director, Davinderjit Singh, to sign the report.


On 10/01/2024 CCLD received an SOC 341 that reported on 09/30/2024 at around 4:00 PM Residents (R1) and (R2) were heard arguing by Staff (S1). The report indicated that S1 intervened and separated R1 and R2. The report further indicated that R1 was observed by S2 bleeding on their leg

LPA interviewed S2 that stated R1 (sitting) and R2 (standing) were both in the bistro area. S2 stated that S1 separated both residents and lead R2 into the activity area. S2 stated that R1 was still sitting down and they observed that R1 had mild bleeding on their lower left leg. S2 stated that R1 reported that R2 hit their leg with R2's walker. S2 stated that they questioned R2 about the alleged incident and that R2 reported that their walker hit R1's walker that caused R1's walker to hit their own leg. S2 stated that they cleaned the laceration on R1's leg and dressed it up. The SOC 341 report indicated that both residents have a diagnosis of dementia. S2 stated that there has not been any further issues between R1 and R2 after that incident.

LPA obtained a copy of resident's roster, physician's reports, medication lists and Individualized Service Assessments for R1 and R2. LPA reviewed that R1 and R2 both have a diagnosis of dementia.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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