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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600314
Report Date: 01/29/2021
Date Signed: 01/29/2021 02:00:16 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/02/2020 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20201202152520
FACILITY NAME:AEGIS ASSISTED LIVING OF SAN FRANCISCOFACILITY NUMBER:
415600314
ADMINISTRATOR:FAIMAFILI HOWARDFACILITY TYPE:
740
ADDRESS:2280 GELLERT BLVD.TELEPHONE:
(650) 952-6100
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:100CENSUS: 58DATE:
01/29/2021
UNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Chris LyonsTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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-Staff did not provide adequate supervision resulting in resident taking another resident hostage and barricading in residents room.

-Staff did not seek timely medical care for residents
INVESTIGATION FINDINGS:
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On 1/29/21 Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced complaint investigation regarding the above allegation. LPA met with Administrator Chris Lyons via tele-visit due to Covid-19 procedures and explained the purpose of the tele-visit.

Regarding the allegation of Staff did not provide adequate supervision resulting in resident taking another resident hostage and barricading in residents room, the Department investigation found the following: during interviews with staff, staff stated that they were redirecting Resident 1 (R1) to come back to the dining area, but R1 did not want to go back. R1 went to the nearest room because he/she did not want to be followed. R1 was not able to close the door due to staff placing a book in between the door. Staff were with R1 the entire time this incident took place.

Regarding the allegation of Staff did not seek timely medical care for residents, the Department found the following:

Report Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
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 2
Control Number 14-AS-20201202152520
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: AEGIS ASSISTED LIVING OF SAN FRANCISCO
FACILITY NUMBER: 415600314
VISIT DATE: 01/29/2021
NARRATIVE
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During record review of Resident 2 (R2), Resident 3 (R3), and Resident 4 (R4) charts, nurses and caretakers wrote daily notes of these residents and any medical issues. Every medical issue that was noted on each resident was addressed and handled by the residents physicians. Residents notes that LPA reviewed has dates and times, and no medical issue was ever addressed a month or even weeks later. These issues were addressed in a timely manner.

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

An exit interview was conducted with Chris Lyons. A copy of this report was provided to Chris Lyons via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 9099 and 9099-C was received. Chris Lyons is to print out the report and fax a signed copy to LPA at 650-266-8841 or email to LPA at Christopher.Hopkins-Clarke@dss.ca.gov.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021
LIC9099 (FAS) - (06/04)
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