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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201060
Report Date: 08/23/2022
Date Signed: 08/23/2022 02:53:44 PM


Document Has Been Signed on 08/23/2022 02:53 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:AEGIS LIVING PLEASANT HILLFACILITY NUMBER:
079201060
ADMINISTRATOR:BALANCIO, ROCHELLEFACILITY TYPE:
740
ADDRESS:1660 OAK PARK BLVDTELEPHONE:
(925) 939-2700
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:90CENSUS: 57DATE:
08/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Linda Fisher, General ManagerTIME COMPLETED:
03:05 PM
NARRATIVE
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On 8/23/2022 at 2:20PM Licensing Program Analysts (LPAs) L. Hall and L. Alexander-Washington conducted an unannounced Case Management visit regarding a hospice initiation that was reported to CCLD on 8/22/2022. LPA met with Linda Fisher, General Manager and explained the purpose of the visit.

The hospice notification that was submitted to CCLD included 3 residents. The residents were admitted to hospice services on 12/07/2021, 05/06/2022, and 5/17/2022. The notification was submitted past the five working days and did not include the date of admission to the facility or the address of the hospice agency.

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

Exit interview conducted. A copy of this report and appeal rights provided

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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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Document Has Been Signed on 08/23/2022 02:53 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: AEGIS LIVING PLEASANT HILL
FACILITY NUMBER: 079201060

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2022
Section Cited

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87632 (d) If the Department grants a hospice care waiver it shall stipulate terms...the waiver... which shall include... requirements: (2) ...notify the Department in writing within five working days of the initiation of hospice care services...This notice shall include... name and date of admission...and the name and address of the hospice. This requirement was not met as evidence by:
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Based on LPA's review the Licensee did not comply with the section cited above in notifying the Department of the hospice admissions, which poses a potential health and safety issue for 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
LIC809 (FAS) - (06/04)
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