015601374-9-7-2023-15-AS-KHOS-CVSJLQ-20230918070908

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601374
Report Date: 09/07/2023
Date Signed: 09/07/2023 01:53:00 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2023 and conducted by Evaluator Liridon Fici

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230831161507

FACILITY NAME:	AEGIS ASSISTED LIVING OF FREMONT		FACILITY NUMBER:	015601374
ADMINISTRATOR:	PAUL H SHEPODD		FACILITY TYPE:	740
ADDRESS:	3850 WALNUT AVENUE		TELEPHONE:	(510) 739-1515
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	110	CENSUS: 81	DATE:	09/07/2023
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Shashi Madahar, Administrator (ADM)		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Licensee did not follow proper eviction procedures for resident.

INVESTIGATION FINDINGS:

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On 9/7/2023 at 9:50 AM Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an initial 10-day complaint investigation visit and to deliver findings on the above allegation. LPA met with Shashi Madahar, Administrator (ADM) and explained the purpose of the visit.

During visit, LPA requested copies of the following documents: Residents moved out report for June 2023, and Eviction letters for three (3) of (3) residents.

LPA interviewed 4 staff members at 11:02 AM.

Continue on Lic9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 15-AS-20230831161507

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AEGIS ASSISTED LIVING OF FREMONT	FACILITY NUMBER: 015601374
	VISIT DATE: 09/07/2023

NARRATIVE

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Continued from Lic9099.

It was alleged that: Licensee did not follow proper eviction procedures for resident. Based on interviews and record review conducted, LPA confirmed with S1 and S2 that R1 was unsafe for the community and R1 needed a higher level of care. S1 and S2 notified Rp about R1’s aggressive behavior and that R1 is a harm to herself, staff and other residents in the community. It was stated by S1 and S2 that R1 did not receive an eviction notice, and that S1 and S2 verbally informed Rp that the community can not meet R1's care needs.

Based on LPAs interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D.

Exit interview conducted with ADM, and a copy of this report provided along with appeal rights.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20230831161507

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AEGIS ASSISTED LIVING OF FREMONT	FACILITY NUMBER: 015601374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/14/2023 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	87224 Eviction Procedures: (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agree to review section 87224- Eviction Procedures and to submit a self-certification with a signature of all community directors acknowledging the above section and to submit a copy to CCL by POC due date.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above by not giving R1 a proper eviction notice to be removed from the community which poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2023 and conducted by Evaluator Liridon Fici

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230831161507

FACILITY NAME:	AEGIS ASSISTED LIVING OF FREMONT		FACILITY NUMBER:	015601374
ADMINISTRATOR:	PAUL H SHEPODD		FACILITY TYPE:	740
ADDRESS:	3850 WALNUT AVENUE		TELEPHONE:	(510) 739-1515
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	110	CENSUS: 81	DATE:	09/07/2023
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Shashi Madahar, Administrator (ADM)		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

1
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9

Facility staff did not properly supervise resident resulting in elopement.

INVESTIGATION FINDINGS:

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5
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7
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13

On 9/7/2023 at 9:50 AM Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an initial 10-day complaint investigation visit and to deliver findings on the above allegation. LPA met with Shashi Madahar, Administrator (ADM) and explained the purpose of the visit.

During visit, LPA requested and obtained copies of the following documents: Residents moved out report for June 2023, Staff roster, Physician reports, and current needs and service plans for three (3) of (3) residents.

LPA interviewed 4 staff members at 11:02 AM.

Continue on Lic9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20230831161507

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AEGIS ASSISTED LIVING OF FREMONT	FACILITY NUMBER: 015601374
	VISIT DATE: 09/07/2023

NARRATIVE

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Continued from Lic9099.

It was alleged that: Facility staff did not properly supervise resident resulting in elopement. Based on interviews conducted, S1, S3, and S4 were supervising R1 while R1 left the facility. Staff did not want to force R1 to come back into the facility and staff walked with R1 to food max store while 911 was called. Rp was informed that R1 left the facility. Rp arrived too food max store and drove S1 and R1 back to the community. No police report was generated.

Based on Interviews conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with ADM, and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5