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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003994
Report Date: 06/25/2021
Date Signed: 06/25/2021 04:35:07 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2020 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200606113405
FACILITY NAME:AEGIS ASSISTED LIVING OF CARMICHAELFACILITY NUMBER:
347003994
ADMINISTRATOR:CHUCK SCHURINGAFACILITY TYPE:
740
ADDRESS:4050 WALNUT AVETELEPHONE:
(916) 972-1313
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:90CENSUS: 75DATE:
06/25/2021
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Donald Stamets, Administrator TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident fell and sustained brain/head injuries while under care of facility staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint the department received on 6/6/2020. LPA met with Donald Stamets, 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. 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: surgical Mask.

During the course of the investigation, the department interviewed multiple facility staff members and managers and reviewed documentation relating to resident (R1), including, but not limited to, hospital medical records, resident's physician report, care plans, incident reports (LIC624), charting notes, Medication Administration Records (MAR), county coroner records and county death certifiate.

The results of the investigation are as follows:

Resident (R1) moved to the facility on/around November 2019 with a diagnosis of Dementia. Resident resided in the memory care unit through 5/26/2020 when he had a fall and was sent out to the emergency room. Interviews indicated that resident's demeanor had changed from the time of moving to the facility to his last fall on 5/26/2020. Initial assessment dated 10/29/2019 states that resident has Dementia and has a potential for falls and requires observation from staff for safety needs.

cont on 9099C(1)...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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 7
Control Number 27-AS-20200606113405
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: AEGIS ASSISTED LIVING OF CARMICHAEL
FACILITY NUMBER: 347003994
VISIT DATE: 06/25/2021
NARRATIVE
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9099C(1).. Resident's physician's report, dated 11/6/2019, notes resident has a diagnosis of Dementia and Seroquel was prescribed to control agitation and aggressive/forceful behaviors. Appraisal dated 11/15/19 notes that resident can be unstable walking, if taking calming medications, calming medications may need to be adjusted/changed, and resident needs special observation/night supervision due to being confused/forgetful/wandering due to Dementia diagnosis. Stability Risk Assessment Form dated 11/20/2019 indicates that resident has balance problems with walking and has had no history of falls in the last 12 months. Care Plans dated 3/18/2020, 12/12/2019 and 11/26/2019 note that resident has a potential for falls and requires observation from staff for safety needs. Care plan dated 12/12/2019 notes that resident needs special observation at night when resident gets up to use the bathroom.

Interview with one staff indicated that resident did not have a 1:1 but could have used one during the daytime hours, as resident became less stable on his feet and was observed to have fallen more than once on a shift. Another staff stated that resident would get up and wander during the night and needed 1:1 supervision to prevent falls. Hospital medical records note that resident's representative indicated to a hospital social worker that resident had a 1:1 caregiver when he first moved to the facility in November 2019 until the Covid19 lock down began, in March 2020. Health and Safety Director stated that resident became more agitated, didn't want to be bothered and was walking a lot more than when he first moved in and wasn't sure if this change was documented in resident's file. Care Director indicated resident was a fall risk and "scooted his feet to walk" and staff tried to keep resident in the common area and checked hourly on him. Care Director added that resident had a few falls, about twice a week, so resident's medications were changed. Health and Services Director stated resident had an "unsteady gate" and would wander everywhere but was in sight every hour within the memory care unit.

Charting notes reflect resident had (5) falls on 1/13/2020, 4/4/2020, 5/14/2020, 5/23/2020 and on 5/26/2020 and was sent out for further medical evaluation on 5/23/2020 and 5/26/2020. Notes and LIC624 received reflect resident was showing increased agitation and combativeness on 5/10/2020 when resident tried to hit a staff member, and inadvertently hit another resident. On 5/15/2020, notes document facility nurse had, a phone appointment with resident's physician and it was discussed that the prescription for Alprazolam (Xanax) .25 mg would be increased from one-half tablet, 3 times per day, to one tablet 3 times per day. MAR for May 2020 shows Alprazolam (Xanax) .25 mg tablet was prescribed to be administered 3x/day effective 5/15/2020 (8:00 pm), as a routine PRN medication, and then prescribed as a scheduled medication effective 5/16/2020 and was administered through 5/26/2020 (8:00 pm).
cont on 9099C(2)...





SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) -26-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20200606113405
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: AEGIS ASSISTED LIVING OF CARMICHAEL
FACILITY NUMBER: 347003994
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2021
Section Cited
CCR
87705(c)(3)(C)
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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. This requirement is not met as evidenced by:


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Licensee/Administrator agree to ensure staff (S2, S3 and S4) complete training as required to be in compliance with medications used for dementia residents. Licensee/Administrator also agree to ensure that all staff who assist residents with Activities of Daily Living (ADL's) also have completed any required annual training. S2 is no longer employed at this facility.
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Based on record review, the Licensee did not ensure that staff recognized the effects of medications commonly used to treat symptoms of dementia and provided resident (R1) with sufficient observation, on 5/26/2020, to ensure his safety needs were met, which posed an immediate health and safety risk to resident in care. Resident fell on 5/26/2020 at approximately 10:45 pm and sustained a serious head injury and passed on 5/31/2020.
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Documentation to be provided to the department by 7/9/2021 by fax or email.

**An immediate Civil penalty in the amount of $500.00 is also being assessed due to the resident sustaining serious bodily injury.
CCR
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20200606113405
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: AEGIS ASSISTED LIVING OF CARMICHAEL
FACILITY NUMBER: 347003994
VISIT DATE: 06/25/2021
NARRATIVE
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9099C(2)...with meeting with resident's representative to discuss "increasingly aggressive behaviors" and later that day, notes indicate Regional Health Services Director e-mailed resident's representative regarding a recommendation from facility's Regional Health Services Consultant to request a referral from resident's physician for a mental health behavioral modification. Charting notes show that a new order for Quetiapine Fumarate (Seroquel) 25 mg was discussed and received on 5/21/2020, prescribing one tablet up to 3 time per day for agitation and a follow up prescription was received for the same medication on 5/25/2020, to be taken 3 times per day for agitation. MAR documentation shows Quetiapine Fumarate (Seroquel) 25 mg, one tablet per day was started on 5/24/2020 at 8:00 am and given through 5/26/2020 (8:00 pm), when resident was sent out to the emergency room following a fall that night.

In addition to the scheduled medications, resident was administered PRN medication Alprazolam (Xanax) .25 mg for agitation on 10 days in May 2020, including on 5/14/2020, 5/23/2020 and 5/26/2020, when resident fell. Additionally, resident was taking the medication Donepezil 5mg, 1 tablet per day from 1/7/2020- 5/26/2020. MAR documentation lists side effects of drowsiness and dizziness for medications, Donepzeil, Alprazolam and Quetiapine. Resident fell on 5/14/2020, 5/23/2020 and on 5/26/2020 and the injuries were more severe with each subsequent fall.

Staff training records were reviewed for (1) caregiver (S2) and (2) med-techs (S3/S4) who regularly assisted resident, including on 5/26/2020, with care and/or administering medication. Record review showed there was no documentation that S2, S3 and S4 had received training on the effects of medications given to treat behaviors associated with Dementia. LPA also reviewed training documentation, provided in March 2021, for caregiver (S1) who works in assisted living, which showed that caregiver last received training in psychotropic medications in December 2019. (See separate 809 for citation).

LIC 624 dated 5/23/2020 notes that when resident was walking around in another resident's room, lost his balance and fell, hitting his head on the corner of the wall, sustaining a bump and small abrasion on the back of his head. EMS report dated 5/23/2020 (10:44 am) note that resident had "previous abrasions to both arms noticed from previous falls. Resident is combative and tried to bite" and refused neck collar. LIC624 states that resident returned to the community the same day at approximately 5:30 pm with no new medication orders received.
cont on 9099C(3)...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20200606113405
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/25/2021
NARRATIVE
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9099C(3)...Charting notes and LIC624 both document that resident fell on 5/26/2020 in his room when a noise was heard coming from resident's room at approximately 10:45 pm. Upon responding, caregiver (S2) found resident on the floor with his head under the TV stand, bleeding from the head and right eye and immediately called Med-Tech (S4) on her walkie. Interview with Med-Tech (S3) stated she checked on resident at approximately 9:45 on 5/26/2020 and resident was sleeping in his bed. Motion sensor records document motion in resident's room on 5/26/2020 at 8:01 pm, 9:36 pm, 10:35 pm and at 10:51 pm.

Emergency Medical Services (EMS) report for 5/26/2020 shows that they were contacted by the facility at 10:48 pm (22:48), arrived on site at 10:59 pm (22:59) and resident's room at 11:02 pm (23:02). EMS documentation also notes that "Staff stated resident had fallen twice earlier the same day. Staff stated resident is usually agitated and combative w/staff." Resident was admitted to the hospital for a cerebral bleed and was discharged on hospice on 5/28/2020 and returned to his home, before passing on 5/31/2020.

Hospital records dated 5/26/20 show "Internal development of scattered extensive intraparenchymal hemorrhage across the bilateral cerebral hemispheres involving all lobes to variable degrees with greatest involvement of the left frontal and temporal lobes", or "bleeding in the soft tissue of the brain," as explained by the attending emergency room physician in an interview with the department and who also confirmed that resident's injuries were consistent with a ground level fall. County Death Certificate notes that resident passed on 5/31/20 and the immediate cause of death was: Alzheimer's Disease. Coroner records document that resident sustained an injury from an unwitnessed fall on 5/26/2020 from care facility, and the manner of death was an accident.

Facility internal incident reports completed by staff for incidents occurring on 5/23/2020 and 5/26/2020 indicate that facility contacted an alternative ambulance medical services instead of 911 for resident to obtain a further medical evaluation. A citation was previously issued on 2/16/2021 and facility completed follow up in-service training.



cont on 9099C(4)..
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20200606113405
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/25/2021
NARRATIVE
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9099C(4)...Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- a finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.


Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is cited.

An immediate civil penalty in the amount of $500.00 is to be assessed for a resident sustaining a serious bodily injury while in care at this facility. As a result of resident’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code §1569.49. At this time, the civil penalty assessment is under review. LPA will return at a future date to assess a civil penalty, if warranted.

Exit interview. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/06/2020 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200606113405

FACILITY NAME:AEGIS ASSISTED LIVING OF CARMICHAELFACILITY NUMBER:
347003994
ADMINISTRATOR:CHUCK SCHURINGAFACILITY TYPE:
740
ADDRESS:4050 WALNUT AVETELEPHONE:
(916) 972-1313
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:90CENSUS: DATE:
06/25/2021
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Donald Stamets, Administrator TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility did not follow resident's care plan.
INVESTIGATION FINDINGS:
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Allegation: Facility did not follow resident's care plan. Care plans dated 3/18/2020, 12/12/2019 and 11/26/2019 note that resident has a "potential for falls and requires observation from staff for safety needs". Care plans dated 3/18/2020 and 12/12/2019 note that resident needs special observation at night when resident gets up to use the bathroom. Additionally, appraisal dated 11/15/19 notes that resident can be unstable walking, if taking calming medications, calming medications may need to be adjusted/changed, and resident needs special observation/night supervision due to being confused/forgetful/wandering due to Dementia diagnosis. Care Director indicated resident was a fall risk and "scooted his feet to walk" and staff tried to keep resident in the common area and checked hourly on him. Care Director added that resident had a few falls, about twice a week, so resident's medications were changed. Health and Services Director stated resident had an "unsteady gate" and would wander everywhere but was in sight every hour within the memory care unit. Motion sensor documents record motion in resident's room on 5/26/2020 at 8:01 pm and again at 9:36 pm, approximately an hour and a half later. Motion was again recorded in resident's room at 10:35 pm, 59 minutes later. LIC624 indicates that resident was checked on by staff (S3) at approximately 9:45 pm and resident was asleep in his bed. LIC624 also states staff (S2) heard a loud noise at approximately 10:45 pm coming from resident's room, and staff entered and found resident on the floor under the TV table stand, bleeding from his head. Motion sensor records document motion again at 10:51 pm, and then not again until 6:05 am on 5/27/2020. Emergency Medical Services (EMS) report for 5/26/2020 shows that they were contacted by the facility at 10:48 pm, arrived on site at 10:59 pm, and at resident's room at 11:02 pm. It cannot be established that the facility did not follow this care plan; however, facility should have updated the care plan, due to a change in condition, when a clear pattern was observed that resident had an increase in the frequency and/or severity of falls. (See 809 for separate citation issued).

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- a finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview. Copy of report given to Administrator
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 7