Aegis Gardens.

On 01/07/2026 at 2:50 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident that was sent on 12/11/2025. LPA met with Director of Operations, Angel Lee, and explained the purpose of the visit. The Executive Director was not available during today's visit. Incident report indicated that on 12/06/2025, R1 was sent to the hospital for a change in condition. On 12/10/2025, the facility was notified by R1's responsible party that R1 was diagnosed with a stage 3 pressure ulcer. During the visit, interview with S1 and a review of the after-visit summary dated 09/26/2025 and 11/21/2025, R1 was diagnosed with stage 2 pressure ulcer. LPA reviewed and obtained Home Health Care Visit Communication Form, Physician Fax Reports, hospital progress notes, and service plan. Documents reviewed indicated that R1's pressure ulcer would reopened once healed. Interview with S1 and Physician Fax Report dated 06/13/2025, revealed that since June 2025, R1's home health was initiated for wound care and home health has been monitoring the wound. Since R1's hospitalization, R1 has not returned from hospitalization. No deficiencies cited. Exit interview conducted with Lee and copy of this report is provided.

On 01/07/2026 at 1:20 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident that was sent on 12/17/2025. LPA met with Director of Operations, Angel Lee, and explained the purpose of the visit. The Executive Director was not available during today's visit. Incident report indicated that Resident 1 (R1) had an unwitnessed fall on 12/16/2025. R1 was experiencing mild pain and was resolved with pain medications. On 12/17/2025, R1 had a change in condition and was sent to the Emergency Room (ER). During the visit, LPA reviewed After Visit Summary, Physician Fax Report Form, Unusual Occurrence Report (Facility Incident Report), Service Plans dated 11/26/2025 and 12/18/2025, and R1's physician report. LPA interviewed 3 staff members. LPA interviewed Staff 1 (S1) and Staff 2 (S2) revealed that R1 is a high risk for falls. A review of R1's service plan indicated that R1 was placed on the additional safety checks throughout the day effective 12/16/2025 and on the Augi sensor system on 11/26/2025. Interview with S2 revealed that communication between family regarding 1:1 care was conducted through the phone after the fall incidents had occured. S3 stated that they heard the motion alarm sound on 12/16/2025, and when they checked on R1, they found R1 on the floor. LPA will be requesting additional communication log between the facility and family regarding 1:1 care services. No deficiencies cited. Exit interview conducted and a copy of this report was provided.

On 10/29/2025 at 12:00 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. The facility sent in an incident report on 10/27/2025 regarding R1's fracture. LPA met with Health Services Director, Gigi Tamayo, and Director of Operations, Angel Lee, and explained the purpose of the visit. The Executive Director was not available during today's visit. LPA P.Manalo received a self-reported incident report from facility that indicated Resident 1 (R1) had unwitnessed fall on 10/25/2025 and started experiencing pain on 10/26/2025. Responsible party brought R1 to the hospital and was treated with lower leg fracture on 10/27/2025. R1 returned to the facility day of with a leg brace. During the visit, LPA interviewed Health Services Director, Gigi Tamayo, and reviewed R1's Individualized Service Plan dated 10/27/2025 and 09/13/2025, Physician Report, and After Visit Summary. No deficiencies cited during visit. Exit interview was conducted with Tamayo and Lee and a copy of this report was provided.

On 10/08/2025 at 12:00 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. The facility sent in an incident report on 08/31/2025 and death report on 10/06/2025 regarding Resident 1 (R1). LPA met with Health Services Director, Gigi Tamayo, and Director of Operations, Angel Lee, and explained the purpose of the visit. The Executive Director was not available during today's visit. LPA P.Manalo received a self-reported incident report from facility that indicated Resident 1 (R1) had unwitnessed fall and was admitted to the hospital for a cervical fracture. On 10/06/2025, LPA received a death report that R1 passed away. LPA reviewed and obtained R1's After Visit Summary dated 04/16/2025, Discharge Summary, Physician Report dated 02/05/2025, Resident Appraisal, Care Plans, and Physician Fax Report. LPA will be requesting full medical record, R1's progress notes dated from April 2025 to October 2025, and death certificate to be sent to CCLD. LPA may return at a later time. No deficiencies cited during visit. Exit interview was conducted with Tamayo and Lee and a copy of this report was provided.

On 04/22/2025 at 10:15 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Executive Director, Emily Poon, and explained the purpose of the visit. LPAs toured the facility inside and out including but not limited to residents' apartments, bathrooms, activity rooms, beauty salon, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 71 degrees F. The hot water temperature in residents’ shared bathroom were measured at 117.1, 112, and 119 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid shower pan. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 06/20/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 03/05/2025. At 10:20am, LPAs reviewed 7 residents records. At 11:25 am, LPAs reviewed 7 staff records and all are associated to the facility. At 1:20 PM, LPAs reviewed two sample of resident’s medications. All records were observed to be complete and up to date. No deficiencies were cited during visit. Exit interview conducted and a copy of this report provided.

On 04/22/2025 at 1:50 PM Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. Executive Director self-reported the incident on 03/31/2025. LPAs met with Executive Director, Emily Poon, and explained the purpose of the visit. LPA P.Manalo received a self-reported incident report from facility that indicated Resident 1 (R1) was admitted for hospitalization for a UTI and internal brain bleed. LPAs record review of the After Visit Summary dated 04/01/2025 shows that R1's internal brain bleed was due to a hemorrhagic stroke. No deficiencies cited during visit. Exit interview was conducted with Executive Director, and a copy of this report was provided.

On this day 09/13/2024 at 2:10 pm, Licensing Program Analysts (LPAs) Patricia Manalo and Luisa Fontanilla arrived to the facility to conduct a case management visit regarding a incident report and met with Executive Director, Emily Poon and explained the purpose of the visit. During the visit, LPAs interviewed R1 and S1 by obtaining an interpreter service. LPAs attempted to interview R1. However, due to R1's dementia, LPAs were unable to obtain relevant information. LPAs interviewed S1 and S1 demonstrated to LPAs how the incident occurred. No deficiencies were cited during visit. Exit interview conducted and a copy of this report provided.

On 6/25/2024 at 12:20PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Director of Operations, Angel Lee and explained the purpose of the visit. The facility’s fire clearance was approved for 85 non-ambulatory of which 48 may be bedridden. LPA toured the facility with Director of Operations including but not limited to 6 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 109.3, 117.8, 111.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Freezer temperature measured at 0 degrees F and refrigerator measured at 40 degrees F. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguishers was last serviced on 6/20/2024. Emergency Disaster Plan was last posted on 6/13/2024. First aid kit was observed to be complete. Fire drill was last conducted on 5/25/2024. At 1:00pm, LPA reviewed 6 residents records. At 2:00pm, LPA reviewed 7 staff records and 6 of 6 have current first aid training and associated to the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 2/15/2024, at 10:10am, Licensing Program Analysts (LPAs), L. Hall and T. Syess, arrived unannounced to conduct a case management visit. LPAs met with Gigi Tamayo, Health Services Director, and explained the purpose of the visit. LPAs arrived to deliver complaint findings from amended complaint dated 6/13/2023. 15-AS-20230613151024. LPAs obtained signatures on amended complaint document LIC9099 and LIC9099C. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 12/13/2023, LPA G. Luk interviewed staff which revealed that escort services were provided to residents. S4 stated that facility was providing small group activities during the 3 COVID outbreaks. S4 stated that residents were escorted to small group activities and walks in the courtyard area. LPA G. Luk reviewed a sample of resident's service delivery records and observed that residents were provided escort services during the 3 COVID outbreaks. Facility emailed residents and family during each COVID outbreak which indicates that dining room will be closed; However, there will be small group activities and exercise in the courtyard was provided. LPA observed activity schedule where small groups activities were conducted at different times. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegation is UNSUBSTANTIATED . No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.