AEGIS GARDENS

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having two storage units in the Life's Neighborhood (Memory Care) courtyard unlocked and accessible to residents in care. Storage units contained chemicals such as paint, Chlorox, and bleach which posed an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/20/2026 Plan of Correction By POC date, Executive Director agrees to lock the storage units and send proof of correction to CCLD.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307(d)(6) Personal Accommodations and Services (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by having chairs blocking the side exit door in the memory care unit which posed a potential safety risk to persons in care.

Official plan of correction

The Administrator agrees to have an in-service training with all staff, create alternative plan for conducting activies in memory care, and send proof to CCLD by POC date.

Deadline recorded: Nov 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4)Additional Personal Rights of Residents in Privately Operated Facilities (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidence by: Based on record review and interview, the licensee did not comply with the section cited above by not providing supervision causing R1 to leave the facility which posed a potential health and safety risk to residents in care.

Official plan of correction

The Executive Director agrees to review resident's physician's report, creating a plan on increasing safety checks with residents with elopement or wandering, and conducting training for staff.

Deadline recorded: Jul 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

87465(e) Incidental Medical and Dental Care:(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician... This requirement is not met as evidenced by: Based on observation, and record review, the licensee did not comply with the section cited above by crushing R1's medication prior to submitting a physicians order to R1's primary physicians to crush medication which poses/posed a immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to submit a self-certification on section 87465(e) Incidental Medical and Dental Care by explaining how will this be avoided in the furture and to understand the reguation. All med techs, administrators, health service directors, nurses, and care directors will date and sign self-certification and submit to CCL by POC due date.

Deadline recorded: Oct 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 (a)(4) Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...(4) To care, supervision, and services that meet their individual needs... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not making sure the physicians order for R1's eye drop medication is being used accordingly. On 6/23/2023, facility staff administered the incorrect amount of eye drops into R1's right eye which poses/posed a immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to set a plan to complete monthly medication training and to complete comtentency check lists every month and to submit proof of medication training and comtentency check list to CCL by POC due date.

Deadline recorded: Sep 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87612(a)(2)

Regulation authority

CCR

What the official deficiency says

87612(a)(2) Restricted Health Conditions: (a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services: (2) Catheter care as specified in Section 87623. This requirement is not met as evidenced by: Based on observation, and record review, the licensee did not comply with the section cited above by not submitting a exception for a restricted health condition for R1, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to request an exception for R1 for a restricted health condition to CCL by POC due date.

Deadline recorded: Jul 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211(a)(1) Reporting Requirements:(a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days... This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above by not submitting incident reports (Lic624s) to CCL regarding R1's falls which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Adminisatror agreed to read and understand section 87211(a)(1)- Reporting Requirements, and to submit a signed self-certification to CCL by POC due date.

Deadline recorded: Jun 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Requirements - General:(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not giving R1 the correct medications and mistakenly giving R1 another residents medication which posed a immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to submit a plan to LPA to conduct additional medication in-service training with a skilled nurse and to have training signed by all med techs and to submit proof of signed in-service training to CCL by POC due date.

Deadline recorded: Jun 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465(c)(2) Incidental Medical and Dental Care: (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by overmedicating R1 with incorrect medication that did not belong to R1 which posed a immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to submit a plan to LPA to write a self-certifcation on section 87465(c)(2)-Incidental Medical and Dental Care and to have all med techs read, understand, and have it signed and to submit a copy of the signed self-certifcation to CCL by POC due date.

Deadline recorded: Jun 7, 2023. A deadline is not proof that correction was completed.