015601374-1-4-2022-15-AS-LHAL-CA7VBK-20211230151740

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601374
Report Date: 12/30/2021
Date Signed: 01/04/2022 01:07:13 PM

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 ASSISTED LIVING OF FREMONT		FACILITY NUMBER:	015601374
ADMINISTRATOR:	SHASHI K MADAHAR		FACILITY TYPE:	740
ADDRESS:	3850 WALNUT AVENUE		TELEPHONE:	(510) 739-1515
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	110	CENSUS: 98	DATE:	12/30/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Cathy Zhou, Health and Services Director and Emily Poon, General Manager		TIME COMPLETED:	03:25 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

This LIC809 is an amendment to the original LIC809 dated 12/30/2021.

On 12/30/2021, Licensing Program Analyst (LPA), L. Hall generated case management visit under this facility. LPA did correct and generate case management visit under the correct facility profile Aegis Gardens #019201063 the same day.

On 12/30/2021 at 1:40PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a case management visit regarding an incident report received on 12/28/2021. LPA met with Health and Services Director, Cathy Zhou and Emily Poon, General Manager.

Incident report dated 12/28/2021 revealed that Resident 1 (R1) reported abuse from Staff 5 (S5). Facility notified law enforcement and R1's responsible party.

LPA interviewed three (3) of four (4) staff. LPA was not able to interview Resident 1 (R1) due to diagnosis. Interview with Staff 1 (S1) revealed that S5 was the caregiver for R1 on the day of the incident. R1 was being assisted by S5 in the bathroom when the incident occurred. R1 reported the incident to Staff (S4). S4 reported the incident to S1. S5 was suspended immediately and after the investigation was terminated on 12/28/2021. Facility will be conducting an abuse training for all staff on 1/5/2022.

LPA collected the following documents: Staff roster, Resident roster, and training documents for S5.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

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 1