Aegis Assisted Living of Moraga

Allegation investigated: Facility did not allow resident to have visitors.

On 05/29/2026 at 11:40 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct an initial 10-day complaint investigation and to deliver findings regarding the allegation above. LPA met with Health Service Director Desirae Gutierrez-Hernandez and explained the purpose of the visit. During the course of the investigation, LPAs obtained copies of the Physician’s Report, Individualized Service Assessment, Resident Emergency Information sheet, Power of Attorney, Restrainging order, and visitor log for R1. LPAs also interviewed S1 and R1. Allegation: Facility did not allow resident to have visitors. Investigation Findings: It was reported to the department that R1 Is not being allowed to have visitors and is being isolated. LPA met with S1 who explained that R1 is very social with both staff and other residents in the community. Continued on LIC9099-C Unsubstantiated Continued from LIC9099 R1 has multiple visitors who come to visit and has not expressed a desire for leaving. S1 also stated, R1 has friends in the facility and can usually be found in the garden talking with other residents or engaging in various facility activities. R1 does have a Power of Attorney (POA), and a restraining order filed that the facility must enforce. The restraining order is only against one person, and the POA does not limit who R1 can visit with or who can come and visit with R1; aside from the person on the restraining order. Review of R1’s visitor log showed R1 has had multiple visitors form outside the facility since moving in. LPA spoke with R1. R1 enjoys visiting with other residents, engaging in various facility activities, and looks forward to the different events planned throughout the day. R1 stated that since a recent procedure, R1 has not been as active in the community as before, but as R1’s strength comes back, R1 is looking forward to socializing more. R1 still has visitors come in and other resident stop by. Based on interviews conducted and record review, the above allegation is UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 1, 2026 · control 15-AS-20260529145745

Type of visit: Required - 1 Year

On 01/21/2026 at 12:30 PM, Licensing Program Analysts (LPA) David Doidge arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with General Manager Tianna Henderson and explained the purpose of the visit. LPA toured the facility including but not limited to, bedrooms, bathrooms, multiple activity rooms, kitchen, and common area. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 113 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 12/30/2025. Emergency disaster drills are conducted monthly, with the last one conducted on XXX. First aid kit was observed to be complete. LPA reviewed five (5) resident records and five (5) staff records, all were complete. No deficiencies observed or cited during this visit. Exit interview conducted and a copy of this report providedthe state’s words, verbatim · CDSS document, Jan 21, 2026

Type of visit: Case Management - Other

On 01/21/2026 at 3:00 PM, Licensing Program Analysts (LPA) David Doidge arrived unannounced to conduct a Case Management visit in regards to a self-reported elopement from the facility. LPA met with General Manager Tianna Henderson and explained the purpose of the visit. It was reported to the LPA that on 01/20/2026 a resident (R1) eloped from the facility. R1 had walked out the front door and across the street to a store. S1 was in the store while on lunch and saw the resident. S1 was able to assist R! back to the facility safely. Staff has been retrained with in-service training and R1 now has a one-on-one. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted with Dolly Rizvi appeal rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 21, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jan 22, 2026

o care, supervision, and ...meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency... This requirement was not met as evidence by Based on self report, the licensee did not comply with the section cited above by not having resident supervision which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 21, 2026

Plan of correction: Staff has been retrained with in-service training and R1 now has a one-on-one.

Allegation investigated: Staff billed resident for services not being rendered by staff Staff did not follow resident's care plan (DNR)

On 10/07/2025 at 12:55 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with General Manager,Tianna Henderson, to deliver the findings of above allegations. LPA explained the purpose of the visit with the General Manager, Tianna Henderson. During the investigation LPAs interviewed Staff regarding allegations and obtained the following documents: Staff Registry, Resident Registry, Individualized Services Assessments, Physician's Report, Resident Face Sheet, Billing Invoices (Jan '24 thru Sept '24), and Admission Agreement. LIC9099-C Continued... Unsubstantiated LIC9099-C (Page 2) Allegation: Staff billed resident for services not being rendered by staff. Finding: Unsubstantiated On 10/30/2024, LPA L. Alexander interviewed Witness (W1). W1 stated that R1’s care plan increased from $15,000.00 to $20,000.00. W1 reported that they were billed for 30 days but only paid for 5 days, at approximately $6,000.00. W1 stated that facility only discussed points but never discussed the money. On 10/31/2024, LPAs Alexander and Doidge interviewed Staff (S1, S2 and S3). S2 stated that R1’s Individualized Service Assessment dated 03/18/2024 totaled 324 points. S2 reported completing a reassessment on 08/06/2024, which resulted in 447 points. S2 explained that once the assessment is completed, the billing department calculates the rate. S2 stated they contacted W1 via email to discuss the new assessment and requested a care conference, but W1 did not respond. S3 reported that they complete resident billing each month. S3 explained that when a new assessment is completed, they enter the total points into the billing system, which calculates the updated rate. S3 stated that they attempted to explain the charges to W1 by phone, but W1 became upset and disconnected the call. S3 further reported that the Responsible Party (RP) removed R1 from the facility on 08/26/2024. S3 also stated: The August billing statement dated 07/18/2024 totaled $15,498.76. A new assessment completed on 08/22/2024 changed the rate to $353.13 per day. This rate applied to the period 08/22/2024 through 09/30/2024 (40 days). Adjustments were made to the account, resulting in a credit of ($6,654.96). Based on interviews and records reviewed, the allegation that staff billed the resident for services not being rendered is unsubstantiated. LIC9099-C Continued... LIC9099-C (Page 3) Allegation: Staff did not follow resident's care plan (DNR). Finding: Unsubstantiated On 10/30/2024, LPA Alexander interviewed Witness (W1), who stated that on July 3, 2023, R1 was under hospice care with Suncrest Hospice and had a “Do Not Resuscitate” (DNR) order in effect. W1 stated that an Aegis Moraga night care staff member summoned paramedics rather than contacting the hospice team. W1 reported being contacted by paramedics who stated that R1 had been resuscitated. W1 further stated that a hospice representative also contacted them immediately and expressed concern regarding a breach of protocol by facility staff. On 10/31/2024, LPAs Alexander and Doidge interviewed Staff (S1, S2 and S4) regarding allegations that CPR (Cardiopulmonary Resuscitation) was rendered to R1, who had a DNR on file, around 07/03/2023. S1 stated they were not aware of this incident and reviewed facility records for any corresponding incident report. S1 stated that no LIC624 (Unusual Incident Report) was found in R1’s file. S2 stated that they were not working at the facility during that time period. S4 was interviewed by phone and stated that if any such incident had occurred, it would have been documented in facility records. S4 stated they do not recall any incident involving R1 that required 911 response or CPR being rendered. On 11/04/2024, LPA Alexander contacted Suncrest Hospice and spoke with W2. W2 confirmed that R1 was discharged from hospice services on 03/14/2023 and re-admitted on 05/26/2023. W2 stated there were hospice notes dated 07/03/2023 for an assessment but nothing in their records indicating a 911 call or CPR performed by emergency personnel. LIC9099-C Continued... LIC9099-C (Page 4) LPA reviewed the Moraga-Orinda Fire District “Patient Care Report” dated 07/03/2023, which documented an EMT response to the facility at approximately 2135 hours. The report indicated that R1 experienced a syncope episode, was conscious, awake, and alert upon EMT arrival, and had no medical complaints. The report revealed that R1 declined transport to the hospital, and the EMT contacted R1’s Power of Attorney, who also declined transport. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that staff failed to follow R1’s care plan or disregarded a DNR order. Records reviewed indicate that while emergency medical services were contacted, no resuscitation efforts were performed, and R1 remained stable at the scene. Although the allegation 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. A copy of this report were provided to General Manager, Tianna Henderson.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 15-AS-20241022215724

Type of visit: Case Management - Incident

On 10/07/2025 at 1:30 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit. LPA met with General Manager, Tianna Henderson and explained the purpose of the visit. While conducting complaint investigation #15-AS-20241022215724, LPA L. Alexander observed during record review and interviews that an incident involving a 911 EMT response for Resident (R1) on 07/03/2023 was not reported to the Community Care Licensing Division (CCLD) as required. Staff (S1) stated they were unaware of the incident involving emergency medical services responding to R1. S1 confirmed that no LIC624 (Unusual Incident Report) was submitted to the Department. Based on information obtained, the facility failed to report an incident involving emergency medical response for a resident to the Department within the required timeframe. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. An exit interview was conducted. A copy of this report and Appeal Rights (LIC9058) were provided to General Manager, Tianna Henderson.the state’s words, verbatim · CDSS document, Oct 7, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 21, 2025

87211(a)(1)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidence by: Based on record review and interviews the licensee did not comply with the section cited above in by not submitting a written report within 7 days of the occurences of any of the events for residents in care. Specifically there were no incident report submitted on around 07/03/23 for when R1 had a EMT response which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: The Administrator will ensure that all staff are re-trained on incident reporting requirements by conducting an In-Service Training with all nurses and med techs including NOC shift. Documentation of staff training sign-in sheet will be submitted to CCLD by due date.

Type of visit: Case Management - Other

On 05/09/2025 at approximately 1:30 PM License Program Analyst (LPA) David Doidge arrived unannounced to conduct a case management visit regarding an Unusual incident report (UIR) that was reported to CCLD on 04/25/2025. LPA met with Tianna Henderson General Manager (GM) and explained the purpose of the visit. LPA Spoke with General Manager and the Medication Care Manager (S1). The UIR stated that the resident was given two (2) tabs instead of one tab as directed on the bubble pack. The incorrect dosage given was caused by an error from the pharmacy. The Pharmacy entered two (2) tabs as the dosage in the Electronic Medication Administrator Record (EMAR) and the bubble pack showed one (1). The Medication Care Manager (S1) caught the error when administering the dose and informed the pharmacy to have EMAR updated. Correct dosage has since been administered. Per GM retraining on medication was also performed. Resident’s spouse and PCP were updated. Resident was monitored with no negative side effects. No deficiencies observed or cited during this visit. . Exit interview conducted and a copy of this report providedthe state’s words, verbatim · CDSS document, May 9, 2025

Allegation investigated: Staff are not allowing resident to have visitors

On 1/14/2025 at 8:15 AM, Licensing Program Analysts (LPAs) James Sampair and David Doidge arrived unannounced to conduct this initial 10-day complaint investigation concerning allegation above. The LPAs met with Executive Director (ED) Maria Angeles Sticka and informed her of the allegation. The complaint alleges that staff are not allowing resident to have visitors. The LPAs reviewed the visitor log. The visitor log showed that between 12/20/2024 and 1/14/2025, resident R1 had 28 visits. 21 of which were from witness W1. The LPAs interviewed the ED about allowing visitors for resident R1. The ED explained that after a threat to her life by W1 on 12/31/2024, the police were called and the visitation rights of W1 were suspended. After a reconciliatory meeting on 1/1/2025 with the ED, W1, and a policeman, the visitation rights for W1 were reestablished. The data collected does not confirm the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 14, 2025 · control 15-AS-20250106123926

Type of visit: Required - 1 Year

On 01/14/2025 at 08:15 AM, Licensing Program Analysst (LPAs) David Doidge and James Sampair arrived unannounced to conduct an annual required inspection. LPAs met with General Manager Angeles Sticka and explained the purpose of the visit. LPA toured the facility including but not limit to, bedrooms, bathrooms, multiple activity rooms, kitchen, and common area. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 72 degrees Fahrenheit. The hot water temperature in a common bathroom was measured at 120 degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps are locked and inaccessible to residents in care. Fire extinguisher was last serviced on 12/18/2024. Emergency disaster drill are conducted monthly, last conducted on 12/20/2024. LPA reviewed five (5) resident records and five (5) staff records, all were complete. No deficiencies observed or cited during this visit. . Exit interview conducted and a copy of this report providedthe state’s words, verbatim · CDSS document, Jan 14, 2025

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) D. Doidge and C. Fowler arrived unannounced to conduct a case management visit in response to the Unusual Incident Report (UIR) for three residents (R1, R2 and R3), that AWOLed, submitted by the facility to the Department. LPAs met with and informed, Angeles Sticka, General Manager, of the purpose of visit. UIR received indicated on September 14. 2024, R1, R2 and R3 AWOLed from facility by opening an alarmed side gate from the memory care's courtyard and walked out. R2 pushed on the door until it opened, R1 and R3 followed. R2 headed left toward the front of the facility and was found by staff in front of the facility. R2 and R3 had walked straight out and were later found a few blocks away by the police. LPAs reviewed of Physician's Report for all three residence that showed dementia and unable to leave the facility unassisted. LPAs toured the facility, observed auditory signals on outer gates for the memory care courtyard. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights, were provided.the state’s words, verbatim · CDSS document, Sep 26, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2 · Plan of correction due date: Oct 10, 2024

(a) In addition to the rights listed in Section 87468.1, .residents...for the elderly shall have all of the following personal rights:(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 is not met as evidence by: based on record review, residence R! R2 and R3 are not able to leave facility unassisted due to diagnosis. Residence AWOLed due to lack of supervision and timely response to alarms.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: By POC date, General Manager agreed to conduct extra training on alarm response with all staff and provide list of attendees for training to CCLD.

Type of visit: Required - 1 Year

On 01/26/24 at 12PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with co-administrator (Co-ADM) and explained the purpose of the visit. Co-ADM has a current administrator certificate # 6041047740 which expires 06/15/2024. At 1:30PM, LPA toured the facility with Co-ADM including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. An electronic sign-in policy, digital scanner temperature device, additional face masks and hand sanitizers were observed at the front desk screening station. LPA observed 2 memory care units located on the first floor with 24 memory care residents. LPA also observed 40 assisted living residents located on the second floor. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 72 deg F. Hot water temperature was measured at 118 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 5 staff and 5 resident files. LPA also conducted 5 staff and 5 resident interviews during visit. Continue on next page, LIC 9099-C At 3:45PM, LPA obtained updated copies of the following documents for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies observed during visit. Exit interview conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Jan 26, 2024

Type of visit: Case Management - Incident

On 12/14/2023 Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced case management visit regarding a SOC 341 self-reported incident that occurred on 12/7/23. LPA spoke with Amria Angeles Sticka, Executive Director and explained the purpose of the visit. LPA received an SOC 341 self-reported regrading a resident hitting another resident well in the community. LPA interviewed S1 regrading the incident. S1 stated that the situation has been resolved. S1 spoke with the victim family members and explained the situation. R1 was being treated for UTI and now is calmed. S1 had the following plan implement. - R1 was being evaluated by the physician. - Internal investigation of the caused of R1 irritation. - R1 was assigned a one on one after that incident. - LVN did an assessment on R2 for any injury (found no injury) LPA reviewed: - Physician Notification - PCP notification of R1 behavior - Change in medication. - S1 Communication between R1 family member regrading R1 change in behavior. - S1 Communication with R2 family member No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Dec 14, 2023

Allegation investigated: Staff do not provide proper incontinence care to residents in care Staff do not provide proper medication assistance to residents in care Facility is not kept clean Facility is not kept free of pests

On 12/04/2023 at 10:15 AM, Licensing Program Analyst P Watson arrived unannounced deliver findings for the above allegations. LPA met with Care Director, Ticarra Boyd and explain the purpose of the visit During the course of the investigation the Department interviewed residents and staff and obtained documents. Documents including but not limited to: Staff roster with contact information, staff schedule for July, August and September, med tech training logs, resident roster, resident care plans, resident progress notes, MARS and LIC 622 for July, August and September, recent Physicians reports. Report continues on 9099 C Unsubstantiated It was alleged that Staff do not provide proper incontinence care to residents in care Based on observations, LPA observed incontinence supplies in the memory care wings, LPA observed a sufficient amount of diapers, wipes and gloves. Based on interviews with staff (S1, S4 and S5), incontinence residents are checked on and changed every 2 hours. When asked about incontinence supplies, S4 and S5 stated that supplies can be low with Hospice residents due to limited supplies and wrong sizes. Based on interview with Care Director (CD), Hospice agencies send incontinence supplies weekly without CD needing to request. Other incontinence supplies are restocked by CD and placed in four different locations (in an unlocked cabinet in the Wellness Center, in a locked area/closet in each memory care wing and in an overstock closet that CD has access to). It was alleged that Staff do not provide proper medication assistance to residents in care Based on interview with CD, med techs (Medication Care Manager), the Associate Care Director, the Wellness Nurse and CD themselves dispense medication. There are seven med techs on staff, and five work during the day (two during AM shifts, two during PM shifts and one during NOC shifts). Based on interview with resident (R1), R1 has not experienced any issues with their medications. R1 stated that staff knocks on their door and dispenses their medications without issues. It was alleged that Facility is not kept clean Based on observations, LPA observed the facility to be clean and without odor. Housekeeping staff were observed cleaning the facility during the initial visit. Based on interviews with staff (S3, S4 and S5), the facility is kept clean. S4 stated that on average they observe housekeeping sanitation three times per their shift. Based on interview with Executive Director (ED), resident apartments are cleaned once a week, unless they have an accident and/or need it to be cleaned more frequently. The whole facility is cleaned every day by housekeeping. Report continues on 9099 C It was alleged that Facility is not kept free of pests Based on observations, LPA did not observe any pests during the initial visit. Based on interviews with staff (S1 and S4), spiders are common in the memory care unit. S4 stated that they have observed spiders, roaches and stated that for some time there was a cricket in one of the hallways in the memory care wing. Based on interviews with Executive Director (ED) and Maintenance Manager (MM), the facility has a contract with Western Exterminator Company, the facility is inspected every month and treated as needed. Staff can report to MM when they observe pest, MM contacts the exterminator and the facility gets treated with the best mode to eliminate pest (such as traps and sprays). Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 4, 2023 · control 15-AS-20230905110825