Aegis Living San Francisco

Type of visit: Required - 1 Year

On 5/28/2026, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Executive Director Cecilia Dauth followed after. LPA explained the purpose of the visit. LPA toured the facility inside and outside including a random sample of resident rooms, common areas & kitchen area. The indoor and outdoor passageways were free of obstruction. LPA observed some residents were in the activity room doing some exercises, there were also residents in the living room area were listening to music. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. There is a fountain in the courtyard and is barricaded so it’s not accessible to residents. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter. LPA reviewed eight resident records and five staff records. Resident records are updated, complete and signed. Staff records are complete, training logs are done through Relias. All medications are accounted for, and centrally stored medication records are updated. No deficiencies are cited at this time. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, May 28, 2026

Type of visit: Required - 1 Year

On 6/16/2025, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator, Cecilia Dauth. LPA explained the purpose of the visit. LPA toured the facility and a random sample of resident rooms, common areas, and kitchen area. Facility has a fenced fountain. LPA observed some residents were at different activity rooms. While touring the facility it was observed that the temperature was at 72 deg F. Hot water was also tested in the resident rooms and the temperature was at 110 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are done every quarter. Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA received the following documents: Certificate of Liability Insurance & LIC500. Administrator to submit certificate once available. No deficiencies are cited at this time. Report is reviewed and a copy is provided.the state’s words, verbatim · CDSS document, Jun 16, 2025

Allegation investigated: Staff did not report an incident involving resident in care as necessary.

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 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 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 2the state’s words, verbatim · CDSS document, Jun 12, 2024 · control 14-AS-20240408125636

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jun 19, 2024

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. 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.the state’s words, verbatim · CDSS document, Jun 12, 2024

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 19, 2024

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... 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.the state’s words, verbatim · CDSS document, Jun 12, 2024

Plan of correction: Licensee to submit a plan to address reporting requirements and provide in-service training for staff. Licensee to submit plan before POC Due Date.

Type of visit: Required - 1 Year

On 6/12/2024, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Cecilia Dauth and explained the purpose of the visit. LPA toured the facility inside and outside including a random sample of resident rooms, common areas, and kitchen area. LPA observed most residents engaged in different activities. Facility has a fountain which is fenced. While touring the facility it was observed that the temperature was at 70 deg F. Hot water was also tested in the resident rooms and the temperature was 110 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. Resident call pendants are functioning. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter. Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic 20hr requirement. Facility has a certified administrator on site with complete certification and training requirements. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA received the following documents: LIC500 Personnel Report, Liability Insurance. No deficiencies are cited at this time. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Jun 12, 2024

Type of visit: Case Management - Incident

On 4/9/24 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit. LPA met with Administrator Cecila Dauth explained purpose of today's visit. LPA received a report on 3/26/24 about an incident that happened on 3/25/24. A referral partner witnessed an altercation between resident (R1) and a family member (F1) in the parking lot. Two person witnessed an elderly slapped on the left cheek and was shoved by force inside a private car. LPA interviewed Administrator (ADM) Cecilia Dauth and Health Services Director (HSD) Hayley Ragasa. Both mentioned that they didn't witness what happened. HSD observed the resident when R1 went back to the facility and there were no apparent injuries. R1 was observed to be in good condition upon returning. No deficiencies cited today. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Apr 9, 2024

Allegation investigated: Staff are not following proper infection control requirements

On 3/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Cecilia Dauth and explained the purpose of today's visit. Regarding the allegation of staff are not following proper infection control requirements, the Reporting Party (RP) stated that there is no PPE for the staff. RP stated that they don’t have any face shields or hair covers. RP stated that all the residents are being isolated except one. LPA interviewed staff members and 6 out of 6 mentioned that there were emergency PPEs provided by the facility. LPA also interviewed Administrator Cecilia Dauth & Wellness Director Hayley Ragasa, both stated that part of their protocol is to have garbage bin and supply outside the rooms of infected residents. This is for when staff enters, they wear the PPE supply and when exiting, throw the PPEs right away on the bin. Face shields are also available when requested by staff. Residents who were infected are isolated in another wing of the facility. One staff member, S1, also mentioned that the residents were provided food in their rooms. Unfounded LPA also toured the storage area where these PPE supplies are stored. LPA has observed enough emergency supply needed for the facility. LPA observed boxes and cabinet full of gloves, boxes of wipes, storage of supplies that are placed outside rooms of residents, boxes of isolation gowns and masks. Based on records review, the infection protocol of the facility states that all staff and volunteers providing direct care to a resident who has a communicable disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, and eye protection. Face shield and hair covers are not a requirement. Receipts are also provided by the facility as proof of additional purchase of PPEs. Therefore, based on the interviews conducted, files reviewed, and information collected, the allegation mentioned is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Mar 19, 2024 · control 14-AS-20240313115017

Allegation investigated: - Residents' room is malodorous - Facility placed a resident in another residents room without notifying responsible party.

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. Substantiatedthe state’s words, verbatim · CDSS document, Jan 12, 2024 · control 14-AS-20230403164840

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 26, 2024

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 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.the state’s words, verbatim · CDSS document, Jan 12, 2024

Plan of correction: Plan/proof of correction to be submitted to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(17) · Plan of correction due date: Jan 26, 2024

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 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.the state’s words, verbatim · CDSS document, Jan 12, 2024

Plan of correction: Plan/proof of correction to be submitted to CCLD BY DUE DATE

Type of visit: Case Management - Deficiencies

During the investigation of complaint #14-AS-20230403164840, a deficiency of the California Code of Regulations, Title 22 was observed. Details follow below, and citation appears on a following page. This requirement was not met, as clients #1 and #2 were roommates for at least two weeks, as documented by facility's internal billing forms. Client #2 was on hospice since 3/17/23 and passed away on 3/31/23. Conservator of client #1 did not provide written consent for client #1 to share room with hospice client, nor was there any notice given that there would be a roommate. Licensee failed to ensure that client #1 or conservator consented to having roommate who was receiving hospice services, which posed a potential health, safety or personal rights risk to client.the state’s words, verbatim · CDSS document, Jan 12, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(h)(5) · Plan of correction due date: Jan 26, 2024

HOSPICE CARE OF TERMINALLY ILL For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain...A statement signed by the resident's roommate, if any, or any resident who will share a room with a person who is terminally ill to be accepted or retained ... indicating his or her acknowledgment that the resident intends to receive hospice care in the facility for the remainder of the resident's life, and the roommate's voluntary agreement to grant access to the shared living space to hospice caregivers, and the resident's support network of family members, friends, clergy, and others. See LIC809.the state’s words, verbatim · CDSS document, Jan 12, 2024

Plan of correction: Plan/proof of correction to be submitted to CCLD BY DUE DATE

Type of visit: Case Management - Incident

On 11/30/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management for an incident report. LPA met with Administrator, Cecilia Dauth & Resident Wellness Director Hayley Ragasa and explained the purpose of today's visit. On 11/27/23, Licensing received a report submitted by the facility with regards to a resident (R1) needing assistance after being found on the floor face down. 911 was called and it was noted that resident had strong alcohol breath. Based on interview with Administrator and Resident Wellness Director, R1 is allowed to have alcohol and they are not able to regulate it unless there is a doctors order and responsible party also gave consent for R1 to drink. Responsible party and Doctor were made aware of the incident. R1 was back in the facility on the same day after tests show negative findings. Care Plan will be updated accordingly. Facility has followed regulations regarding residents personal rights. No citations are issued at this time. Report is reviewed and a copy is provided.the state’s words, verbatim · CDSS document, Nov 30, 2023

Allegation investigated: Facility staff does not help facilitate communication between reporting party and resident Facility staff chemically restrained the resident

On 11/07/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Administrator, Cecilia Dauth & Resident Wellness Director Hayley Ragasa and explained the purpose of today's visit. Regarding the allegation of facility staff does not help facilitate communication between reporting party (RP) and resident (R1). It was reported that the facility is not helping RP communicate with R1. During the investigation, LPA interviewed staff members and five out of eight staff mentioned that there are no issues with regards to any family members calling to speak to residents. The only times that a phone call might not go through is when a resident is agitated, sleeping, is on an activity or having meals. In cases or residents with dementia, residents might not be lucid at that time or don’t even remember who they are talking to. The facility is also able to transfer calls so that residents will be able to talk to family members who call. Families are also encouraged to visit, especially for residents who are in hospice. Unsubstantiated Two staff members also mentioned that when R1 gets a call, they give the phone to R1. However, R1 sometimes doesn’t understand or know how to communicate due R1s cognitive disorder. Based on records review, RP sent timelines where in RP was able to get in contact with R1 by calling the facility. There were also instances where another family member calls RP due to the request of R1. The visitation logs only showed that RP only visited the resident once since being admitted to the facility. Regarding the allegation facility staff chemically restrained the resident. RP mentioned that R1 is always in mood stabilizers because of R1s agitation and was always tired. Based on records review, R1 has trouble sleeping and was prescribed Trazodone to help assist. Trazodone was given as a PRN medication and is to be administered after dinner if needed. R1 was prescribed Trazodone starting March of 2023. During this month R1 was given 7 doses on different days. In April 2023, R1 was given 2 doses on different days also. The following months there were no more records of Trazodone being given. A total of just 9 doses from the time it was prescribed were administered. LPA interviewed two Medical Technicians, and both observed that when R1 is given Trazodone, R1 gets groggy and is then assisted to bed. Both Administrator and Wellness Director stated that the facility is not able to chemically restrain residents. Any medication given to residents are doctor prescribed. Facility only follows doctors’ directions and just report if there are any changes to the resident. Therefore, based on the interviews conducted, files reviewed, and information collected, the allegations mentioned are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Report is reviewed and a copy is provided.the state’s words, verbatim · CDSS document, Nov 7, 2023 · control 14-AS-20230628150627