015601374-2-23-2022-15-AS-KHOS-CKBPJP-20221018112152

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601374
Report Date: 02/23/2022
Date Signed: 02/23/2022 06:02:38 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/17/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220217144949

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: 95	DATE:	02/23/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Paul Shepodd, Administrator & Sashi Madahar- health and services director		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff are not adequately trained.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 02/23/2022 at 3:00PM Licensing Program Analyst (LPA) L. Ibo arrived unannounced to in order to meet the 10-day requirement for notification of the above allegation. LPA met with Paul Shepodd, new Administrator and Shashi Madahar, health services director of the facility, LPA explained the purpose of the visit.

LPA conducted interview, based on the interview with the staff, facility had incident where night shift staff does not know where the medication key was kept, S2 admitted that staff was newly hired and not trained.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

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

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

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 3

Control Number 15-AS-20220217144949

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 ASSISTED LIVING OF FREMONT	FACILITY NUMBER: 015601374
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/11/2022 Section Cited CCR 87411(d)(6)	1 2 3 4 5 6 7	(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job... (6) Knowledge of community services and resources. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will conduct a staff training for all staff in related to regulation cited, documentation of training need to be submitted on the POC date.
	8 9 10 11 12 13 14	Based on the observation and interview, the licensee failed to ensure that the facility staff was properly trained which poses to the health and safety and/or personal rights of clients 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: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/17/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220217144949

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: 95	DATE:	02/23/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Paul Shepodd, Administrator & Sashi Madahar- health and services director		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not provide resident's responsible party of updates in resident's condition.
Facility did not have sufficient staff to meet the resident's needs.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 02/23/2022 at 3:00PM Licensing Program Analyst (LPA) L. Ibo arrived unannounced to in order to meet the 10-day requirement for notification of the above allegation. LPA met with Paul Shepodd, new Administrator and Shashi Madahar, health services director of the facility, LPA explained the purpose of the visit.

Based upon records reviewed and interviews conducted the above allegations is unsubstantiated. Facility contacted R1’s family on any change of condition, based on records review facility had sufficient staffing. .

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview was conducted with Paul S. & Sashi M.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 3