347003994-8-2-2022-25-AS-SCAA-CGWVVJ-20220802164624

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003994
Report Date: 08/02/2022
Date Signed: 08/02/2022 04:46:32 PM

Document Has Been Signed on 08/02/2022 04:46 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:	04:00 PM
MET WITH:	Bill Phelps, Interim Administrator		TIME COMPLETED:	04:50 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 Bill Phelps, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA 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 she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N 95 mask. On June 25, 2021, the Department concluded a complaint investigation which alleged the following: Resident (R1) fell and sustained brain/head injuries while under care of facility staff. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, section § 87705(c)(3)(C): § 87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: (C) Recognizing the effects of medications commonly used to treat the symptoms of dementia. Additionally, the licensee was cited for violating CCR Tile 22 § 87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in section § 87467, Resident Participation in Decision Making and Health and Safety Code §1569.625 Staff training; legislative findings; 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)

Page: 1 of 3

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

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
26
27
28
29
30
31
32

809C(1)..contents (c) The training shall include, but not be limited to, all of the following: (7) Dementia care, including the use and misuse of antipsychotics, the interaction of drugs commonly used by the elderly, and the adverse effects of psychotropic drugs for use in controlling the behavior of persons with dementia.

During the complaint investigation a review of R1’s facility file was conducted. File records indicated R1 had 5 falls which occurred on January 13, 2020, April 4, 2020, May 14, 2020, May 23, 2020, and May 26,2020. Specifically, on May 14, 2020, R1 cut the skin on their elbow and was given first aid treatment at the facility; on May 23, 2020, R1 hit their head as a result of a fall and was sent to the ER, and on May 26, 2020, R1 hit their head as a result of a fall and suffered extensive cerebral hemorrhaging and was admitted to the hospital. (According to mayoclinic.org, Intraverbal hemorrhage “cerebral hemorrhage” is defined as a collection of blood within the skull. It's most commonly caused by the rupture of a blood vessel within the brain or from trauma such as a car accident or fall. The blood collection can be within the brain tissue or underneath the skull, pressing on the brain). Multiple caregivers stated to the Department on August 11, 2020, and August 12, 2020, that R1 needed one-on-one care, constant supervision while awake due to wandering, and falling behavior. Interviews with caregivers revealed that R1 had more falls than were documented by facility staff. There is no evidence obtained that facility staff updated R1’s care plans due to R1’s change in condition, specifically due to R1 sustaining multiple falls and being a fall risk. Similarly, there is no evidence from the investigation that the facility took steps to reduce additional falls. In conclusion, there is sufficient evidence that facility staff violated regulations in failing to act on R1’s change in condition and by lack of sufficient care and supervision of R1, which resulted in R1 suffering severe cerebral hemorrhaging from a fall which required medical intervention.

Based on records review, the licensee did not ensure that R1’s care plan was updated during the month of May 2020, when it was observed that there was a clear pattern to the frequency and severity of the falls R1 incurred, while taking medications with a side effect warning of dizziness and drowsiness. Moreover, the licensee did not ensure that staff was properly trained in order to care for R1, who had Dementia. Specifically, there was no documentation provided by the facility that staff (S2, S3 and S4) had received the required annual training in understanding the effects of medications used to treat behaviors associated with Dementia and the use, misuse and interaction of antipsychotic drugs. Based on documentation review, these staff had not received this specific training at all or within the last 12 months, as required.

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)

Page: 2 of 3

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

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
26
27
28
29
30
31
32

809C(2)..At the time of the Case Management visit on June 25, 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.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of or protracted loss or impairment of 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 will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount $10,000. However, since an immediate civil penalty of $500 was issued on June 25, 2021, the amount today will be $9,500.

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

Exit interview conducted. Appeal Rights provided. A copy of the report issued. Administrator Bill Phelp’s signature on this report acknowledges receipt of these rights, found on page 2 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)

Page: 3 of 3