079201060-1-4-2024-15-AS-LAWN-CZ73CM-20240104170811

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201060
Report Date: 01/04/2024
Date Signed: 01/04/2024 05:08:18 PM

Document Has Been Signed on 01/04/2024 05:08 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 HILL		FACILITY NUMBER:	079201060
ADMINISTRATOR:	LINDA L. FISHER		FACILITY TYPE:	740
ADDRESS:	1660 OAK PARK BLVD		TELEPHONE:	(925) 939-2700
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	90	CENSUS: 71	DATE:	01/04/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Linda Fisher, General Manager		TIME COMPLETED:	05:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 01/04/2024 at 12:00PM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit regarding an incident that was reported to Community Care Licensing (CCL) on 12/24/2023. LPA met with both General Manager, Linda Fisher and Care Director, Yelba Havelhorst and explained the purpose of the visit. General Manager informed LPA that Health Services Director, Maria Collado, LVN was phoned and will be arriving shortly to assist with the reported incident. CCL received an Unusual Incident /Injury Report on 12/24/2023 that reported that Resident 1 (R1) was visited by nurse from home health agency and informed Staff 1 (S1) that R1's wound located on buttocks was not getting better and have spread. The report further stated that R1 was unable to get out of their bed and was having difficulty turning and repositioning. S1 completed an assessment and noted that R1's wound located on buttocks had redness on surrounding areas and also have increased in size. LPA Staff Interview: S1 stated that she went to Stanford Hospital in Palo Alto, CA on 03/06/2022 to conduct an Individualized Service Assessment (pre-appraisal) on R1 prior to admission to the facility. S1 stated that R1 was assessed for potential skin breakdown due to R1's paraplegic medical condition and urinary catheter. LIC809-C Continued....

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

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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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: 01/04/2024

NARRATIVE

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LIC809-C Continued....

S1 stated that R1 moved in the facility on 03/11/2022. S1 stated that she completed another Individualized Service Assessment (i.e., appraisal) and the assessment reported, "Resident has increased risk and potential for skin breakdown(s). Care Staff conducts routine checks to identify new skin issues and reports to Nurse." This appraisal also reported, "Staff manages all aspects of resident catheter as follows: supplies management, clean up, documentation and coordination with external services if appropriate."

S1 stated that on 03/24/2022 she completed a skin assessment and noted results on "Skin Assessment & Braden Pressure Scale" that reported a red rash on right forearm. S1 stated that R1 was admitted with a Veterans Affairs (V.A.) Nurse Case Manager (NCM). NCM would call to check on R1 as well as physically come to the facility and check on R1's care needs (e.g., wheelchairs, hospital bed, incontinence care...).

S1 stated that on 04/05/2023 is when the Wellness Nurses (facility licensed nursing staff) noticed a wound on R1's upper posterior leg and perfomed wound/skin care to R1. Wellness Nurses contacted the facility's in-house doctor. One of the Wellness Nurses contacted NCM on 04/10/2023 to inform of R1's wound and to request skin and wound supplies. S1 stated that on 04/12/2023 R1 was seen by a V.A. doctor. S1 states that there was no doctor's orders for medications. However, S1 stated that the doctor gave instructions to "...continue to clean and cover the wound."

S1 stated that on 04/13/2023 R1 was transported to John Muir Emergency Department for a wound check. S1 stated that there was no infection and R1 was discharged the same day.

LIC809-C Continued....

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC809 (FAS) - (06/04)

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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: 01/04/2024

NARRATIVE

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LIC809-C Continued (Page 3)

S1 stated that R1 continued to have his wound check by home health and CNM as well as checking and caring for R1's Foley Catheter.

S1 stated that the home health agency was coming 2 x's a week to wound care R1's wound. S1 stated that in between the days that the home health was making their visits that the Wellness Nurses were also checking and caring for R1's wound. S1 stated that on 12/18/2023 she completed an assessment on R1's wound and felt that the wound was not getting better. S1 stated

LPA received the following documents:

1. Admission Agreement
2. Physician's Report dated 09/22/23 and 11/24/23
3. Initial Assessment dated 03/06/22
4. Care Plan Assessment 03/11/22
5. Skin Assessment 03/24/22
6. home health visit starting 07/10/23 thru 12/13/23
7. nurses notes 01/16/23 thru 12/18/23
8. skin observation forms 06/21/23 and 11/06/23 11/15/23 12/04/23
9. temporary service plan 03/20/23 12/07/23
10. wound care documented 04/24/23 thru 08/19/23
11. John Muir Hospital Visit Summary 04/13/23
12. V.A. Palo Alto Hospital Summary 07/07/23
13. physician fax report 04/17/23

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC809 (FAS) - (06/04)

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