079201060-1-4-2024-15-AS-LAWN-CZ73BG-20240104170619

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201060
Report Date: 01/04/2024
Date Signed: 01/04/2024 05:06:35 PM

Document Has Been Signed on 01/04/2024 05:06 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:	10:00 AM
MET WITH:	Linda Fisher, General Manager		TIME COMPLETED:	12:00 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 10:00AM Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct a case management visit to follow-up on a incident report and death report received by Community Care Licensing on 11/10/2023. LPA met with both General Manager, Linda Fisher and Care Director, Yelba Havelhorst and explained the purpose of the visit. Staff 1 (S1) stated that on 11/04/2023 at approx. 6pm, Resident 1(R1) fell in the dining room after getting up from dinner. S2 assessed R1 and applied first aid to R1's laceration on forehead. 911 was called and R1 was transported to John Muir Hospital In Walnut Creek (John Muir). S1 stated that she went to John Muir to pick up R1 after 9pm because R1 was getting discharged. S1 stated that the Emergency Room (ER) nurse at John Muir informed that R1 was weak and would need a wheelchair. S1 stated that R1 was independent and really did not want to use a wheelchair but went ahead and used the wheelchair. S3 stated that on 11/06/2023 they were looking for R1 to go to dinner. S3 stated that when the resident returned back from the hospital R1 was weak and using a wheelchair. S3 stated that R1 was "very independent." S3 stated at around 5pm they went to R1's apartment and found R1 unresponsive faced down on the floor. S3 stated, "knew that he was gone." S3 further stated that it appeared that R1 was trying to place his clothes on. S3 stated that the police arrived and pronounced R1 deceased. S3 stated that the paramedics also were called and arrived on the scene and pronounced R1 deceased. LIC809-C

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

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LIC809-C Continued....

R1 passed away on 11/06/2023 with an unknown cause of death. During today's visit LPA obtained additional information pertaining to R1's death:

1. Resident Incident Report (Aegis Living Pleasant Hill) dated 06/03/22
2. Unusual Incident Report (LIC 624) dated 10/23/23
3. Physician's Report (LIC 602A) dated 05/26/23
4. Individualized Service Plan dated 10/04/23

LPA requested from facility a copy of R1's death certificate.

LPA was informed by General Manager that family will provide R1's death certificate, once available and will provide CCL a copy.

No deficiencies cited during this visit. Exit interview conducted and a copy of this report 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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