<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601101
Report Date: 06/12/2024
Date Signed: 06/12/2024 04:08:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
04/08/2024 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240408125636
FACILITY NAME:AEGIS LIVING SAN FRANCISCOFACILITY NUMBER:
415601101
ADMINISTRATOR:CECILIA DAUTHFACILITY TYPE:
740
ADDRESS:2280 GELLERT BLVDTELEPHONE:
(650) 952-6100
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:100CENSUS: 65DATE:
06/12/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Cecilia DauthTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not report an incident involving resident in care as necessary.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/12/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator (ADM), Cecilia Dauth and LPA explained the purpose of today's visit.

LPA Donato interviewed three staff members during the course of the investigation.

Regarding the allegation of staff did not report an incident involving resident in care as necessary, RP stated that no one told F1 that R1 sustained any injuries. F1 visited R1 on 03-13-24 and asked R1 how he/she was. R1 said his/her leg hurt. F1 pulled up the pants and saw a 4'5" gash with dried blood, as well as the two bruises.

During the interview S2 mentioned that the bruising was not reported to management.

page 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
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 5
Control Number 14-AS-20240408125636
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: AEGIS LIVING SAN FRANCISCO
FACILITY NUMBER: 415601101
VISIT DATE: 06/12/2024
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
LPA also reviewed incident reports submitted to Licensing and it was found out that this incident was also not reported upon knowledge of the incident.

Based on interviews, the above allegations are determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Copy of Report and Appeals Rights are provided.

Page 2 of 2
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 14-AS-20240408125636
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: AEGIS LIVING SAN FRANCISCO
FACILITY NUMBER: 415601101
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/19/2024
Section Cited
CCR
87466
1
2
3
4
5
6
7
87466 Observation of the Resident 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. ... 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.
1
2
3
4
5
6
7
Licensee to submit a plan to address staff observation and reporting and provide in-service training for staff. Licensee to submit plan before POC Due Date.
8
9
10
11
12
13
14
This was not met as evidenced by:
Based on interviews, S2 confirmed that the bruising was not reported by staff to management, which poses an immediate health, safety, or personal rights risk to clients in care.
8
9
10
11
12
13
14
Type B
06/19/2024
Section Cited
CCR
87211(a)(1)(D)
1
2
3
4
5
6
7
87211 Reporting Requirements(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including... (1)A written report shall be submitted... This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name... (D)Any incident which threatens the welfare, safety or health of any resident...
1
2
3
4
5
6
7
Licensee to submit a plan to address reporting requirements and provide in-service training for staff. Licensee to submit plan before POC Due Date.
8
9
10
11
12
13
14
This was not met as evidenced by:
Based on records review, Licensee did not submit an incident report regarding R1s bruising, which poses an immediate health, safety, or personal rights risk to clients in care.
8
9
10
11
12
13
14
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: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
04/08/2024 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240408125636

FACILITY NAME:AEGIS LIVING SAN FRANCISCOFACILITY NUMBER:
415601101
ADMINISTRATOR:CECILIA DAUTHFACILITY TYPE:
740
ADDRESS:2280 GELLERT BLVDTELEPHONE:
(650) 952-6100
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:100CENSUS: 65DATE:
06/12/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Cecilia DauthTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure that resident's wheelchair was properly locked resulting in resident sustaining injuries.
Staff did not respond to requests for communication regarding resident in a timely manner.
Facility's phone system is in disrepair.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/12/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator (ADM), Cecilia Dauth and LPA explained the purpose of today's visit.

Regarding the allegation of staff did not ensure that resident's wheelchair was properly locked resulting in resident sustaining injuries, reporting party (RP) stated that the responsible party (F1) saw the resident (R1) trying to stand up to look at the screen. F1 said R1 slipped out of the new wheelchair which apparently wasn't locked and sustained a laceration to her left ankle area and two bruises on both sides of the laceration.

Page 1 of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20240408125636
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: AEGIS LIVING SAN FRANCISCO
FACILITY NUMBER: 415601101
VISIT DATE: 06/12/2024
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
LPA interviewed S1 and it was mentioned that R1 was having a zoom call with the family members during this time. S1 was passing by the R1s rooms and saw that R1 was on the floor. S1 then proceeded to assist R1 back on the wheelchair and when asked didn’t mention any discomfort or pain. The wheelchair was locked when S1 was assisting R1.

Based on records review, part of a police report that R1 stated that he/she was having a zoom meeting with family members, tried to get up from the wheelchair, loss balance and fell. R1 also mentioned being ok and that he/she is happy and pleased with the staff.

Regarding the allegation that staff did not respond to requests for communication regarding resident in a timely manner and the facility’s phone system is in disrepair, RP stated that RP tried calling facility on Friday, Saturday & Sunday. Sometimes they picked up the phone but was never able to get a hold of staff and was unable to leave a message as the phone tree system was not working.

LPA interviewed S2 & S3 and both mentioned that when the phone line is not answered, the family members or responsible parties have the direct line. So even if the main phone number is not available, they can call the mobile numbers of either the administrator or resident care director.

Based on interviews and record reviews, the department has determined that although these allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed and copy is provided.

Page 2 of 2
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5