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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601101
Report Date: 01/12/2024
Date Signed: 01/12/2024 03:42:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
04/03/2023 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230403164840
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:
01/12/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Cecilia DauthTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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- Residents' room is malodorous

- Facility placed a resident in another residents room without notifying responsible party.

INVESTIGATION FINDINGS:
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Based on observations and review of records, these allegations are substantiated. The preponderance of evidence standard has been met.

During initial complaint visit on 4/11/23, LPAs Jeung and Donato visited all 17 memory care apartments, and detected the smell of urine in 3 rooms, despite the overwhelming floral scent of a cleaner/disinfectant product and that LPAs were wearing surgical masks.

As confirmed by staff and indicated in facility's billing records, client #2 was relocated to room 101 with client #1 on 3/14/23. There was no notice given to conservator of client #1 about this new living arrangement.

Deficiencies of the California Code of Regulations, Title 22, are cited on a following page.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
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 3
Control Number 14-AS-20230403164840
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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: 01/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2024
Section Cited
CCR
87303(a)
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MAINTENANCE AND OPERATION
The facility shall be clean, safe, sanitary and in good repair at all times.
This requirement was not met, as in 3 out of 17 rooms in Life's Neighborhood, the smell of urine was detected on 4/11/23 by LPAs Jeung and Donato. Licensee failed to
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Plan/proof of correction to be submitted to CCLD BY DUE DATE
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ensure the cleanliness of rooms, as indicated by the presence of urine odor, despite the distinct floral scent of a cleaner/disinfectant product and that LPAs were wearing surgical masks. This posed a potential health, safety or personal rights risk to clients in care.
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Type B
01/26/2024
Section Cited
CCR
87468.2(a)(17)
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ADDITIONALL PERSONAL RIGHTS
In addition to the rights listed in Section 87468.1, residents in privately operated RCFEs shall have the right to share a room with ... a person of their choice when both ... residents live in the facility and both consent to the arrangement. This requirement was
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Plan/proof of correction to be submitted to CCLD BY DUE DATE
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not met, as conservator of client #1 was not notified when client #2 was relocated to room 101 with client #1 on 3/14/23. Licensee failed to ensure the personal rights of client #1 to consent to having a roommate, which posed a potential health, safety or personal rights risk to client.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
04/03/2023 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230403164840

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:
01/12/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Cecilia DauthTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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- Facility did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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Pertaining to the personal belongings of deceased resident, it cannot be determined that facility failed to safeguard items. This allegation is determined to be unsubstantiated.

Upon the death of client 3--spouse of client 1--on 8/31/22, personal belongings remained in the room with the surviving spouse, whose conservator instructed staff not to remove any items. However, during initial complaint visit on 4/11/23, LPAs were advised by administrator that some personal belongings of client 3 were put in a plastic bag and removed from the apartment. The bag was observed stored in the beauty salon and identfied as belonging to client 3. Some items were identified by complainant as missing. However, no personal property was documented by clients' conservator as entrusted to facility upon admission.

Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3