347003994-10-27-2022-25-AS-APEZ-CKYMVG-20221108085643

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003994
Report Date: 10/27/2022
Date Signed: 10/27/2022 03:32:55 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/13/2022 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20221013111936

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: 69	DATE:	10/27/2022
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Danelle Houle, Business Office Manager		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Facility does not have an operational fire alarm system

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Business Office Manager (BOM), Danelle Houle, to deliver findings into the complaint allegation listed above. LPA wore an N-95 mask. Facility staff wore masks while on the premises.

During the investigation, LPA conducted interviews and requested documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility does not have an operational fire alarm system

** Report continued on 9099-C **

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

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 25-AS-20221013111936

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AEGIS ASSISTED LIVING OF CARMICHAEL	FACILITY NUMBER: 347003994
	VISIT DATE: 10/27/2022

NARRATIVE

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Interview conducted with Administrator indicated that they noticed that fire alarm system wasn't working in July 2022. Administrator stated that they notified the home office that alarm needs to be fixed and a work order was created in July of 2022. Administrator stated that staff were conducting fire watch rounds from July 2022 to October 2022 before Metro Fire took over fire watch. LPA observed documents showing Maintenance Coordinator and NOC shift Med-Tech conducting fire watch before Metro Fire took over fire watch. Administrator stated that the facility is under contract with Matsom Alarm and has the alarm system scheduled to be fixed no later than November 1^st, 2022.

Interview with staff member S1 indicated that they were made aware of the alarm system being partially inoperable sometime in the Spring of 2022 (February, March, or April). S1 stated that home office was notified at the time system was observed to be partially inoperable and staff were trained on how to use the system in its current condition. S1 stated that a technician working on the fire alarm panel caused half of the system to short out, causing half of over 300 devices not reporting to the main panel. While all over 300 devices will work individually, half will not report the location of the fire or notify local fire department that there is a fire. S1 could not identify which devices were not reporting to main panel or what portions of the facility were affected. S1 stated that fire alarm company used by facility were supposed to replace parts back in Spring of 2022, but system was too old to replace parts.

Interviews with Administrator, S1, and staff member S2 indicated that the fire alarm system is still partially inoperable. As of today's inspection on 10/27/2022, the fire alarm system at the facility is still partially inoperable. LPA obtained documents regarding fire alarm system as well as fire watch documents before after and Metro Fire took over fire watch during investigation.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with BOM. A copy of this report and appeal rights were provided. BOM's signature on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20221013111936

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AEGIS ASSISTED LIVING OF CARMICHAEL	FACILITY NUMBER: 347003994
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/27/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/28/2022 Section Cited CCR 87203	1 2 3 4 5 6 7	87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will submit fire watch logs to department daily until fire alarm system is fixed. Facility will complete a plan for when and how the fire alarm system will be fixed. Facility will submit plan to LPA by POC due date of 10/28/2022.
	8 9 10 11 12 13 14	Based on interviews conducted, the facility did not esnure that they had a completely operatable fire alarm system, which poses an immediate health, safety, and personal rights risk to residents 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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC9099 (FAS) - (06/04)

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