079201060-8-1-2023-15-AS-LAWN-CUA4KH-20230731191022

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201060
Report Date: 07/31/2023
Date Signed: 08/01/2023 09:20:39 PM

Document Has Been Signed on 08/01/2023 09:20 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/01/2023 08:36 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

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	This is an amended report from visit 7/31/2023. On 07/31/2023 at 12:10 PM, Licensing Program Analysts (LPAs) L. Alexander and L. Fontanilla arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Health Services Director, Maria Collado and Care Director, Yelba Havelhorst and explained the purpose of the visit. The General Manager, Linda Fisher, was not available but arrive shortly there after. The facility’s fire clearance was approved for 90 Non-Ambulatory, of which 5 may be Bedridden. Hospice Care Waiver granted for 13 residents. LPAs toured the facility with Yelba including but not limited to 8 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees F in assisted living and 76 degrees in memory care. The hot water temperatures in a sample of residents’ shared bathroom were measured at 118.1, 115.8, 116 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. At 1 PM, LPA reviewed 5 residents and 5 staff records. The following deficiencies were observed: At 1:45 PM LPAs observed missing non-skid mats in residents' shower located in assisted living and memory care. At 1:49 PM LPAs observed "Goof Off" Disinfectant Spray unlocked cabinet located in Laundry Room downstairs. LIC 809-C Continued....

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AEGIS LIVING PLEASANT HILL	FACILITY NUMBER: 079201060
	VISIT DATE: 07/31/2023

NARRATIVE

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LIC 809 Continued...

At 1:51 PM LPAs observed 2 bottles of Anti-bacterial All Purpose Cleaner unlocked under kitchen cabinet in Memory Care (Aggie).
At 1:55 PM LPAs observed vitamins and Extra Strength Tylenol in residents' rooms in assisted living
At 1 PM, LPAs observed during record review 1 of 5 staff missing First Aid certification.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/31/2023 07:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AEGIS LIVING PLEASANT HILL	FACILITY NUMBER: 079201060
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents...shall receive initial and annual training. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in not having 1 of 5 staff complete First Aid Training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/14/2023
	Plan of Correction
1 2 3 4	Administrator will review all staff files to ensure all staff have current First Aid/CPR training. Administrator will send in self-certification stating all staff have completed First aid and CPR training.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 08/01/2023 09:14 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/01/2023 08:44 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AEGIS LIVING PLEASANT HILL	FACILITY NUMBER: 079201060
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by not having disinfectant cleaning chemicals inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/14/2023
	Plan of Correction
1 2 3 4	Administrator will lock up disinfectant cleaning chemicals. Administrator will conduct a training with staff on keeping toxic chemicals inaccessible to residents. Administrator will send a copy of training and signatures of staff present to training to CCL by POC Due Date.

Type A

Section Cited

CCR

87309(b)

Care of Persons with Dementia

(b) Medicines which are centrally stored shall be stored as specified in Section 87465 and separately from other items specified in (a) above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in by not having vitamins and Extra Strength Tylenol inaccessible to residents which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/14/2023
	Plan of Correction
1 2 3 4	Administrator will remove vitamins and Extra Strength Tylenol from resident's rooms. Administrator will have a discussion with residents and their families about storing medications in their rooms. Administrator will review regulations and have a training with staff. Administrator will send a copy of training with signatures of attendees to CCL by POC Due Date

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: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC809 (FAS) - (06/04)

Page: 3 of 7

Document Has Been Signed on 07/31/2023 07:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AEGIS LIVING PLEASANT HILL	FACILITY NUMBER: 079201060
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(5)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in by not having non skid mats available in residents' showers which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/14/2023
	Plan of Correction
1 2 3 4	Administrator will purchase non skid mats and place in residents' shower where non skid mats are missing. Administrator will send a copy of invoice receipt for non skid mats to CCL by POC Due Date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC809 (FAS) - (06/04)

Page: 5 of 7