347003994-8-2-2022-25-AS-SCAA-CGWVU4-20220802164407

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003994
Report Date: 08/02/2022
Date Signed: 08/02/2022 04:44:18 PM

Document Has Been Signed on 08/02/2022 04:44 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	AEGIS ASSISTED LIVING OF CARMICHAEL		FACILITY NUMBER:	347003994
ADMINISTRATOR:	BILL PHELPS		FACILITY TYPE:	740
ADDRESS:	4050 WALNUT AVE		TELEPHONE:	(916) 972-1313
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	90	CENSUS: 75	DATE:	08/02/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Bill Phelps, Interim Administrator		TIME COMPLETED:	04:00 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 August 2, 2022, Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced and met with Administrator, Bill Phelps, and explained the purpose of inspection. Prior to initiating today’s inspection, LPAs completed required COVID-19 testing protocols, contacted the facility to confirm there are currently no positive COVID-19 diagnoses, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. Additionally, LPA was screened per COVID-19 precautionary measures upon entering the community. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. On February 16, 2021, the Department concluded a complaint investigation which alleged the following: Facility staff failed to provide adequate supervision which resulted in resident (R1) sustaining a fracture, resulting in death. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87705(c)(3)(C): § 87466 Observation of the Resident which states; “The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.” Two additional citations were issued following the investigation pertaining to; 1) Violating CCR Title 22 § 87705 ( c )(4) Care of Persons with Dementia which states; “(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional safety and health care needs as identified in his/her current appraisal.”; cont on 809C(1)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AEGIS ASSISTED LIVING OF CARMICHAEL	FACILITY NUMBER: 347003994
	VISIT DATE: 08/02/2022

NARRATIVE

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809C(1)...and 2) Violating CCR Title 22 for § 87405 Administrator - Qualifications and Duties (h) which states; “The administrator shall have the responsibility to: (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs, including those services identified in the residents' Pre-Admission Appraisals, specified in section § 87457, Pre-admission Appraisal, and Reappraisal, as specified in section 87463.”

The investigation revealed that on July 18, 2020, staff (S3) indicated they heard a loud crash while on route to replenish needed supplies. S3 found resident (R1) at the base of a four-stair corner landing, face down, with the wheelchair on top of R1, bleeding significantly from their head. Records indicated S3 immediately radioed S1, who subsequently called 9-1-1. Records reviewed indicated that 9-1-1 was contacted at 12:51 a.m. on July 18, 2020, and R1 was subsequently transported to the emergency room. Hospital medical records indicated that R1 was admitted to the emergency room on July 18, 2020 at 1:25 a.m., with a diagnosis of Traumatic Cerebral Intraparenchymal Hematoma, a closed fracture of right zygomatic bone, a subarachnoid hemorrhage, a closed left acetabular fracture closed blow out fracture of the right orbital floor; and R1 was placed on hospice. R1 was scheduled to return to the facility on July 19, 2020, but passed away at the hospital later that day at 6:05 p.m.

A review of the facility’s motion sensor records in R1’s room confirmed the alert was activated at 12:23 a.m. and again at 12:31 a.m. on July 18, 2020. It was also confirmed that motion sensor alerts are sent directly to the on-call staff’s pager noting, “MOTION” in a specified room. Records reviewed confirmed that S1 was the only staff working the Assisted Living Unit of the facility on the NOC shift of July 18, 2020. Further, S1 stated during their interview that they did not receive an alert from R1’s motion sensor on the aforementioned date. A review of the pendant response logs during the NOC shift on July 18, 2020, revealed that S1’s pager was functioning properly, and that S1 was responding in a timely manner to pendant alerts. Specifically, a review of the pendant response log revealed that S1 was responding to pendant calls for R2 at 12:02 a.m., R3 at 12:14 a.m., and R4 at 12:21 a.m. S1 did not receive another pendant call until 3:33 a.m. Thus, S1 had approximately twenty-eight minutes to respond to R1’s motion sensor.

Records reviewed during the investigation revealed that R1’s physician’s report dated May 15, 2019, indicated a primary diagnosis of dementia, needs “fall supervision,” and is wheelchair bound. Additionally, R1’s care plan dated April 15, 2020, indicated that R1 had a potential for falls, confusion and memory loss related to time and place orientation, poor safety judgment, and evening confusion. cont on 809C(2)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AEGIS ASSISTED LIVING OF CARMICHAEL	FACILITY NUMBER: 347003994
	VISIT DATE: 08/02/2022

NARRATIVE

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809C(2).. Interviews conducted with multiple staff from July 2020 to January 2021, revealed that due to R1’s cognitive decline, R1 should have been in the memory care unit. However, according to multiple staff, due to R1 being physically fairly independent, R1 continued to reside on the second floor of the assisted living portion of the facility. Multiple staff specifically stated that R1 was forgetful at times, woke up sometimes at night, and attempted to get into their wheelchair. Staff further stated that R1 was confused about their surroundings, especially at night, and would sometimes ask where their room was. Staff also stated during interviews that R1 became more confused and wandered more after the COVID lockdown and appeared more agitated at night in the weeks preceding their death. On July 17, 2020, the evening prior to R1’s fall down the steps, S2 stated that R1 was reportedly more confused than usual during their shift between 6:00 p.m. and 6:30 p.m., and that R1 went to the wrong room twice, and was found wandering downstairs around 7:45 p.m. Further, interviews with staff S1 and S2 confirmed that these changes were not conveyed by S2 to S1 at shift change, as S2 ended their shift one hour early, at approximately 9:00 p.m. on July 17, 2020. Lastly, the licensee did not ensure that the Administrator provided the necessary services that R1 needed by updating R1’s care plan to reflect changes observed by staff.

Based on interviews conducted and documentation reviewed, the licensee did not ensure that observed changes in R1’s condition were addressed or documented in a timely manner. On July 18, 2020, at 12:23 a.m. and 12:31 a.m., R1’s room motion sensor was activated, however, S1 failed to respond to R1’s motion sensor alert, which resulted in R1 sustaining a Traumatic Cerebral Intraparenchymal Hematoma, a closed fracture of right zygomatic bone, a subarachnoid hemorrhage, and a closed left acetabular fracture closed blow out fracture of right orbital floor, which ultimately led to their death. The County Death Certificate listed the immediate cause of death as traumatic brain injury due to a fall from the steps. Due to R1’s increased confusion, forgetfulness, agitation and wandering worsening during the weeks prior to their death, S1’s failure to respond to the motion alert in R1’s room on July 18, 2020, provides sufficient evidence that the facility staff failed to provide the care and supervision required to keep R1 safe, while residing on the second floor.

At the time of the case management visit on February 16, 2021, an immediate civil penalty in the amount of $500 was issued, and the license was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety code § 1569.49.

cont on 809C(3)...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AEGIS ASSISTED LIVING OF CARMICHAEL	FACILITY NUMBER: 347003994
	VISIT DATE: 08/02/2022

NARRATIVE

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809C(3)...The Department has concluded an analysis and has determined that a civil penalty is warranted for the death resulting from serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as “An injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, August 2,, 2022, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 in the amount of $15,000 for a violation that the Department determines resulted in the death of R1. However, since an immediate civil penalty of $500 was issued on February 16, 2021, the amount today will be $14,500.

A copy of the LIC 421D was given to Administrator, Bill Phelps, and originals were signed.

Exit interview conducted. A copy of the report issued. Appeal Rights provided
Administrator Bill Phelps’s signature on this report acknowledges receipt of these rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC809 (FAS) - (06/04)

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