Aegis Living Pleasant Hill

On 01/07/2026 at 09:30 AM, Licensing Program Analysts (LPAs) David Doidge and Andrew Christy arrived unannounced to conduct a case management regarding an Unusual Incident Report sent in by the facility. LPAs met with Care Director Yelba Havelhorst and explained the purpose of the visit. LPAs met with staff and spoke with Executive Director Linda Fisher via phone call. LPAs interviewed staff for more information regarding the incident that occurred on 12/30/2025 around 6:30 PM. LPAs also obtained Progress Notes for the resident name in the Unusual Incident Report. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 11/7/2025 at 5:00 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct a case management visit to deliver an immediate exclusion letter. The LPA met with Administrator Linda Fisher and informed her of the reason for the visit. During visit, the LPA hand delivered the immediate exclusion letter for S1 to the Administrator. The LPA was informed that S1 was not working at the facility and was terminated November 4, 2024. No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided.

On 06/25/2025 at 12:00 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with General Manager, Linda Fisher and explained the purpose of the visit. The facility’s fire clearance was approved for capacity ninety (90) non-ambulatory of which five (5) may be bedridden. Hospice waiver approved for thirteen (13) residents. Administrator certificate #7017208740 expires 09/27/2026. LPA toured the facility with Care Director, Yelba Havelhorst, including but not limited to two (2) 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 74 and 76 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 108.4, and 114.5 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. 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 26 27 28 29 30 31 32 LPA reviewed nine (9) residents records. LPA reviewed ten (10) staff records and 10 of 10 have current first aid training and associated to the facility. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 07/02/2025: LIC 308 Designation of Administrative Responsibility - Reviewed LIC 309 Administrative Organization - Reviewed LIC 500 Personnel Report - Obtained LIC 610E Emergency Disaster Plan - Reviewed Liability Insurance - Reviewed Current Administrator’s Certificate - Reviewed No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 11/07/2024 at 4:10 PM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to Community Care Licensing Division (CCLD) on 10/06/2024. LPA met with General Manager, Linda L. Fisher and explained the purpose of the visit. GM, Linda L. Fisher, had to leave and authorized Health Services Director, Davinderjit Singh, to sign the report. On 10/06/2024 CCLD received an Unusual Incident Report (UIR) that reported the community fence that is on shared property with neighbors was on fire on 10/02/2024. The report indicated that the fire department was called and blazed out the burning fire to the fence. LPA interviewed S1 that stated it was approximately 9:50pm when they were going to the parking lot and observed that there was a fire on the other side of the fence. S1 stated that they called their co-worker to call 911. S1 stated that their car was right at the fence where the fire was burning along with three (3) other cars that belong to staff members. LPA interviewed S2 that stated that approximately 10pm they were sitting in their car on the other side of the building and observed that there was a fire. S2 stated that they called 911 and asked the employees that were parked by the fence to move their cars. S2 stated that the fire department came and put the fire out immediately. LPA interviewed S3 that stated that the fire department did not find anything that caused the fire. The UIR indicates that the General Manager, Linda L. Fisher had a meeting with the homeowner regarding repairs to the fence. LPA observed that the fire damaged fence is boarded up with plywood. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 11/07/2024 at 2:40 PM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to Community Care Licensing Division (CCLD) on 07/30/2024. LPA met with General Manager (GM), Linda L. Fisher and explained the purpose of the visit. GM, Linda L. Fisher, had to leave and authorized Health Services Director, Davinderjit Singh, to sign the report. On 07/30/2024 CCLD received an Unusual Incident Report (UIR) that reported that Residents (R1) and (R2) were both in a physical altercation on 07/29/2024. The report indicated that R1 was found laying on the floor with R2 standing nearby. The report further indicated that R1 and R2 were in a dispute regarding money that was allegedly removed from R2's room. LPA interviewed S1 that stated the nurse called to check on R1 while on the floor and asked R1 if they had any pain and R1 responded, "yes." S1 stated that they called 911 and R1 was transported to the emergency department for further evaluations at Kaiser Walnut Creek. S1 stated that R1 returned back to the facility, all acute testing came back normal and R1 had a doctor's order for pain management. S1 stated that staff was advised to keep both residents separated. LPA obtained a copy of resident's roster, physician's reports, medication lists and Individualized Service Assessments for R1 and R2. LPA reviewed that R1 has a diagnosis of dementia. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 11/07/2024 at 5:10 PM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to Community Care Licensing Division (CCLD) on 10/01/2024. LPA met with General Manager, Linda L. Fisher and explained the purpose of the visit. GM, Linda L. Fisher, had to leave and authorized Health Services Director, Davinderjit Singh, to sign the report. On 10/01/2024 CCLD received an SOC 341 that reported on 09/30/2024 at around 4:00 PM Residents (R1) and (R2) were heard arguing by Staff (S1). The report indicated that S1 intervened and separated R1 and R2. The report further indicated that R1 was observed by S2 bleeding on their leg LPA interviewed S2 that stated R1 (sitting) and R2 (standing) were both in the bistro area. S2 stated that S1 separated both residents and lead R2 into the activity area. S2 stated that R1 was still sitting down and they observed that R1 had mild bleeding on their lower left leg. S2 stated that R1 reported that R2 hit their leg with R2's walker. S2 stated that they questioned R2 about the alleged incident and that R2 reported that their walker hit R1's walker that caused R1's walker to hit their own leg. S2 stated that they cleaned the laceration on R1's leg and dressed it up. The SOC 341 report indicated that both residents have a diagnosis of dementia. S2 stated that there has not been any further issues between R1 and R2 after that incident. LPA obtained a copy of resident's roster, physician's reports, medication lists and Individualized Service Assessments for R1 and R2. LPA reviewed that R1 and R2 both have a diagnosis of dementia. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 11/07/2024 at 3:40 PM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding a death that was reported to Community Care Licensing Division (CCLD) on 08/16/2024. LPA met with General Manager, Linda L. Fisher and explained the purpose of the visit. GM, Linda L. Fisher, had to leave and authorized Health Services Director, Davinderjit Singh, to sign the report. On 08/16/2024 CCLD received a Death Report (LIC624A) that a caregiver found R1 laying on the floor by their bed. The report indicated that R1 was last seen by a Med Tech at around 11:15 AM and was reminded about lunch on 08/16/2024. LPA interviewed S1 and they stated that the caregiver found R1 laying on the floor and that R1 was not breathing. S1 stated that 911 was called and the paramedics and police arrived. S1 stated that the paramedics arrived and assessed R1 but there was no sign of life. The LIC624A further indicated that paramedics pronounced R1 deceased on 08/16/2024 at approximately 12:30 PM. The LIC624A further indicated that R1 had a Do Not Resuscitate (DNR) on file. Police Officer investigated and called the coroner to remove the remains. Police Report #24-2378. LPA reviewed and obtained a copy of R1's physician's report. LPA requested a copy of death certificate to be submitted to CCLD. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 06/18/2024 at 10:45 AM, Licensing Program Analysts (LPAs) L. Alexander and L. Holmes arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Health Services Director, Davinderjit Singh and explained the purpose of the visit. General Manager (GM), Linda Fisher, arrived shortly after. The facility’s fire clearance was approved for capacity of non-ambulatory 90 (ninety) residents. In which 5 (five) may be bedridden. Hospice waiver approved for 13 (thirteen) residents. Administrator Certificate #6049700740 expires 09/27/2024. LPAs toured the facility with Maintenance and Housekeeping Director, Noel Samonte and Linda Fisher (GM) including but not limited to 6 (six) residents’ apartments, bathrooms, multiple activity rooms, 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 76, 75 and 71 degrees F. LPAs 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 112.7, 113.0, 115.2 and 114.5 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. LPAs reviewed 7 residents records. LPAs reviewed 6 staff records and 5 of 6 have current first aid training and associated to the facility. LIC809-C Continued... 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 26 27 28 29 30 31 32 LIC809-C Continued... Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/25/2024: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 01/04/2024 at 12:00PM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit regarding an incident that was reported to Community Care Licensing (CCL) on 12/24/2023. LPA met with both General Manager, Linda Fisher and Care Director, Yelba Havelhorst and explained the purpose of the visit. General Manager informed LPA that Health Services Director, Maria Collado, LVN was phoned and will be arriving shortly to assist with the reported incident. CCL received an Unusual Incident /Injury Report on 12/24/2023 that reported that Resident 1 (R1) was visited by nurse from home health agency and informed Staff 1 (S1) that R1's wound located on buttocks was not getting better and have spread. The report further stated that R1 was unable to get out of their bed and was having difficulty turning and repositioning. S1 completed an assessment and noted that R1's wound located on buttocks had redness on surrounding areas and also have increased in size. LPA Staff Interview: S1 stated that she went to Stanford Hospital in Palo Alto, CA on 03/06/2022 to conduct an Individualized Service Assessment (pre-appraisal) on R1 prior to admission to the facility. S1 stated that R1 was assessed for potential skin breakdown due to R1's paraplegic medical condition and urinary catheter. LIC809-C Continued.... 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 26 27 28 29 30 31 32 LIC809-C Continued.... S1 stated that R1 moved in the facility on 03/11/2022. S1 stated that she completed another Individualized Service Assessment (i.e., appraisal) and the assessment reported, "Resident has increased risk and potential for skin breakdown(s). Care Staff conducts routine checks to identify new skin issues and reports to Nurse." This appraisal also reported, "Staff manages all aspects of resident catheter as follows: supplies management, clean up, documentation and coordination with external services if appropriate." S1 stated that on 03/24/2022 she completed a skin assessment and noted results on "Skin Assessment & Braden Pressure Scale" that reported a red rash on right forearm. S1 stated that R1 was admitted with a Veterans Affairs (V.A.) Nurse Case Manager (NCM). NCM would call to check on R1 as well as physically come to the facility and check on R1's care needs (e.g., wheelchairs, hospital bed, incontinence care...). S1 stated that on 04/05/2023 is when the Wellness Nurses (facility licensed nursing staff) noticed a wound on R1's upper posterior leg and perfomed wound/skin care to R1. Wellness Nurses contacted the facility's in-house doctor. One of the Wellness Nurses contacted NCM on 04/10/2023 to inform of R1's wound and to request skin and wound supplies. S1 stated that on 04/12/2023 R1 was seen by a V.A. doctor. S1 states that there was no doctor's orders for medications. However, S1 stated that the doctor gave instructions to "...continue to clean and cover the wound." S1 stated that on 04/13/2023 R1 was transported to John Muir Emergency Department for a wound check. S1 stated that there was no infection and R1 was discharged the same day. LIC809-C Continued.... 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 26 27 28 29 30 31 32 LIC809-C Continued (Page 3) S1 stated that R1 continued to have his wound check by home health and CNM as well as checking and caring for R1's Foley Catheter. S1 stated that the home health agency was coming 2 x's a week to wound care R1's wound. S1 stated that in between the days that the home health was making their visits that the Wellness Nurses were also checking and caring for R1's wound. S1 stated that on 12/18/2023 she completed an assessment on R1's wound and felt that the wound was not getting better. S1 stated LPA received the following documents: 1. Admission Agreement 2. Physician's Report dated 09/22/23 and 11/24/23 3. Initial Assessment dated 03/06/22 4. Care Plan Assessment 03/11/22 5. Skin Assessment 03/24/22 6. home health visit starting 07/10/23 thru 12/13/23 7. nurses notes 01/16/23 thru 12/18/23 8. skin observation forms 06/21/23 and 11/06/23 11/15/23 12/04/23 9. temporary service plan 03/20/23 12/07/23 10. wound care documented 04/24/23 thru 08/19/23 11. John Muir Hospital Visit Summary 04/13/23 12. V.A. Palo Alto Hospital Summary 07/07/23 13. physician fax report 04/17/23 No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.

On 01/04/2024 at 10:00AM Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct a case management visit to follow-up on a incident report and death report received by Community Care Licensing on 11/10/2023. LPA met with both General Manager, Linda Fisher and Care Director, Yelba Havelhorst and explained the purpose of the visit. Staff 1 (S1) stated that on 11/04/2023 at approx. 6pm, Resident 1(R1) fell in the dining room after getting up from dinner. S2 assessed R1 and applied first aid to R1's laceration on forehead. 911 was called and R1 was transported to John Muir Hospital In Walnut Creek (John Muir). S1 stated that she went to John Muir to pick up R1 after 9pm because R1 was getting discharged. S1 stated that the Emergency Room (ER) nurse at John Muir informed that R1 was weak and would need a wheelchair. S1 stated that R1 was independent and really did not want to use a wheelchair but went ahead and used the wheelchair. S3 stated that on 11/06/2023 they were looking for R1 to go to dinner. S3 stated that when the resident returned back from the hospital R1 was weak and using a wheelchair. S3 stated that R1 was "very independent." S3 stated at around 5pm they went to R1's apartment and found R1 unresponsive faced down on the floor. S3 stated, "knew that he was gone." S3 further stated that it appeared that R1 was trying to place his clothes on. S3 stated that the police arrived and pronounced R1 deceased. S3 stated that the paramedics also were called and arrived on the scene and pronounced R1 deceased. LIC809-C 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 26 27 28 29 30 31 32 LIC809-C Continued.... R1 passed away on 11/06/2023 with an unknown cause of death. During today's visit LPA obtained additional information pertaining to R1's death: 1. Resident Incident Report (Aegis Living Pleasant Hill) dated 06/03/22 2. Unusual Incident Report (LIC 624) dated 10/23/23 3. Physician's Report (LIC 602A) dated 05/26/23 4. Individualized Service Plan dated 10/04/23 LPA requested from facility a copy of R1's death certificate. LPA was informed by General Manager that family will provide R1's death certificate, once available and will provide CCL a copy. No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided.

On 08/01/2023 at 10:42 AM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit to amend an Deficiency/POC which was cited from the previous visit on 07/31/2023. LPA met with General Manager, Linda Fisher and explained the purpose of the visit. LPA received a copy and reviewed R1's and R2's Physicians Reports. Technical Advisory, CCR 87309(a), for scissors observed by LPA in R2's room on 07/31/2023. A copy of the amended report was provided to Linda Fisher.

On 08/05/2022 at 9:40 AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct Infection Control Inspection. LPA met with Health Services Director, Maria Collado and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and courtyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. No deficiencies cited during visit. Exit conducted and a copy of this report provided.

On 05/24/21 at 3PM, a Component III presentation was also completed by LPA D Panlilio during the pre-licensing inspection with the general manager (GM). LPA discussed the most common deficiencies cited for Residential Care Facilities (RCFEs) with GM. LPA discussed with GM the CA Title 22 regulations sections for each deficiency and corrective actions needed to clear citations as wells as how to avoid them. GM agreed to stay in compliance with Title 22 regulations. He stated that he attends the CCLDs & CALA informational calls offered and has shared updated Provider Information Notices (PINs) with staff, residents and authorized representatives.

On 05/24/21 at 2PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced pre-licensing visit and met with the general manager (GM). LPA explained the reason for the visit. LPA observed all staff wearing face masks at the facility. A COVID-19 screening station with electronic visitor's log, temperature probe and hand sanitizer were observed by the front entrance. LPA along with GM toured the facility inside and outside including but not limited to resident's bedrooms, bathrooms, dining room, common living areas, kitchen, and outside patios. There is sufficient lighting around the facility. Resident's rooms were equipped with the proper furniture and lighting. Resident's rooms had proper bedding and linens. Bathrooms were equipped with grab bars, nonskid mats, and hygiene items. Living room is equipped with the proper furniture for the residents. Communal dining areas had dining tables and chairs distanced 6 feet apart. All toxins and sharp objects were locked. Passageways and hallways were free of obstruction. Fire extinguishers were last inspected on 10/23/2020 and are throughout the facility. Smoke detectors and Carbon Monoxide detectors were observed operational. Medication room cabinets were locked and first aid kit was complete. All exit doors in the facility are equipped with auditory signals. Hot water temperature was measured at 106.5 degrees Fahrenheit. LPA observed sufficient perishable (2 days) and nonperishable (3 weeks supply) in the kitchen area. LPA observed the emergency/disaster plan, State License, residents' personal rights, rights to councit. complaint and ombudsman posters displayed in common areas. LPA observed no deficiencies during this visit and that the facility is ready to be licensed. This report will be submitted to the Central Applications Branch (CAB) and a final review of the application will be conducted. This facility is subject to the final approval by CAB. Additional requirements may still be required. Exit interview conducted and a copy of this report provided to GM.