Inspection Reports for Aegis Living Pleasant Hill
1660 Oak Park Blvd, Pleasant Hill, CA 94523, United States, CA
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, including the most recent annual inspection on June 25, 2025, which was clean and showed compliance with safety and record-keeping standards. Earlier reports included a substantiated complaint in July 2024 where the facility failed to report a resident elopement promptly and lacked sufficient supervision and safety measures, indicating issues with resident safety and staffing. Other investigations involved resident altercations and incidents, all substantiated but handled appropriately without deficiencies cited. Several complaint investigations were unsubstantiated, and minor issues such as unlocked cleaning supplies and missing non-skid mats were noted in 2023 but were isolated. The facility’s record shows improvement over time, with recent inspections free of deficiencies and no enforcement actions or fines listed in the available reports.
Deficiencies per Year
8
6
4
2
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 76
Capacity: 90
Deficiencies: 0
Jun 25, 2025
Visit Reason
The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.
Findings
No deficiencies were cited during the visit. The facility was found to have adequate fire clearance, proper lighting, appropriate hot water temperatures, and secure storage of medications and hazardous materials. Staff records and resident records were reviewed and found compliant.
Report Facts
Residents' records reviewed: 9
Staff records reviewed: 10
Staff with current first aid training: 10
Fire clearance capacity: 90
Hospice waiver residents: 13
Hot water temperature: 108.4
Hot water temperature: 114.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda L. Fisher | General Manager | Met with Licensing Program Analyst during inspection |
| Yelba Havelhorst | Care Director | Accompanied Licensing Program Analyst during facility tour |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the inspection |
| Bennett Fong | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 90
Deficiencies: 0
Nov 7, 2024
Visit Reason
An unannounced Case Management visit was conducted regarding an incident reported on 2024-07-30 involving a physical altercation between two residents on 2024-07-29.
Findings
The investigation found that one resident was found on the floor after the altercation and was transported to the emergency department for evaluation. The resident returned with normal test results and a doctor's order for pain management. Staff were advised to keep the residents separated. No deficiencies were cited during the visit.
Complaint Details
The complaint involved a physical altercation between Residents R1 and R2 related to a dispute over money. The incident was substantiated by the report and follow-up evaluation.
Report Facts
Capacity: 90
Census: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda L. Fisher | General Manager | Met with Licensing Program Analyst during visit and authorized Health Services Director to sign report |
| Davinderjit Singh | Health Services Director | Authorized to sign the report on behalf of General Manager |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 90
Deficiencies: 0
Nov 7, 2024
Visit Reason
The visit was an unannounced Case Management inspection conducted regarding an incident reported to the Community Care Licensing Division about a fire on the community fence on 10/02/2024.
Findings
The inspection found that the fire department responded promptly to the fire on the fence, which was extinguished without identifying a cause. The damaged fence was observed to be boarded up with plywood. No deficiencies were cited during the visit.
Complaint Details
The visit was triggered by an Unusual Incident Report about a fire on the community fence. Interviews with staff confirmed the fire and response. The fire department did not find a cause for the fire. The General Manager met with the homeowner regarding fence repairs.
Report Facts
Capacity: 90
Census: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda L. Fisher | General Manager | Met with Licensing Program Analyst during inspection and authorized Health Services Director to sign report |
| Davinderjit Singh | Health Services Director | Authorized to sign the report in place of General Manager |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 90
Deficiencies: 0
Nov 7, 2024
Visit Reason
An unannounced Case Management visit was conducted regarding a death reported to Community Care Licensing Division on 2024-08-16.
Findings
The investigation found that a resident was discovered deceased with a Do Not Resuscitate order on file. Paramedics and police responded, and no deficiencies were cited during the visit.
Complaint Details
The visit was triggered by a death report involving a resident found on the floor not breathing. The death was confirmed by paramedics and the police investigated, calling the coroner to remove the remains.
Report Facts
Facility capacity: 90
Census: 76
Death report date: Aug 16, 2024
Time of death: 1230
Police report number: 242378
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda L. Fisher | General Manager | Met with Licensing Program Analyst during visit and authorized Health Services Director to sign report |
| Davinderjit Singh | Health Services Director | Authorized to sign the report on behalf of General Manager |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Bennett Fong | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 90
Deficiencies: 0
Nov 7, 2024
Visit Reason
An unannounced Case Management visit was conducted regarding an incident reported on 10/01/2024 involving two residents who were heard arguing and one resident was observed bleeding on their leg.
Findings
The investigation found that the incident involved two residents with dementia who had a minor altercation resulting in a mild leg laceration. The staff intervened appropriately, cleaned and dressed the wound, and no further issues were reported. No deficiencies were cited during the visit.
Complaint Details
The complaint was substantiated by the investigation which confirmed the incident between residents R1 and R2, including the minor injury to R1's leg caused indirectly by R2's walker.
Report Facts
Capacity: 90
Census: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda L. Fisher | General Manager | Met with Licensing Program Analyst during inspection and authorized Health Services Director to sign report |
| Davinderjit Singh | Health Services Director | Authorized to sign the report on behalf of General Manager |
| Lori Alexander | Licensing Program Analyst | Conducted the unannounced Case Management visit |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 90
Deficiencies: 3
Jul 25, 2024
Visit Reason
An unannounced Case Management visit was conducted regarding an incident reported on 05/30/2024 involving a resident who eloped from the facility on 05/26/2024.
Findings
The facility failed to report the elopement incident to the Community Care Licensing Division within 24 hours and did not have sufficient supervision or safety measures in place, including the resident not having a 'Wander Guard' device, posing potential health and safety risks to residents.
Complaint Details
The visit was triggered by a complaint regarding a resident elopement incident. The complaint was substantiated by findings that the facility did not report the incident timely and lacked adequate supervision and safety measures.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to report incidents threatening resident welfare, safety, or health within 24 hours. | Type B |
| Insufficient staff numbers, qualifications, and competency to meet individual resident needs. | Type B |
| Failure to implement safety measures for residents with dementia, including lack of awareness that the resident exited the facility. | Type B |
Report Facts
Capacity: 90
Census: 73
Deficiencies cited: 3
Plan of Correction Due Dates: Aug 1, 2024
Plan of Correction Due Dates: Aug 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Bennett Fong | Licensing Program Manager | Supervised the inspection. |
| Yelba Havelhorst | Care Director | Interviewed during the inspection regarding the incident. |
| Davinderjit Singh | Health Services Director | Interviewed during the inspection regarding the incident. |
| S1 | Staff member who provided statements about the resident elopement. |
Inspection Report
Annual Inspection
Census: 72
Capacity: 90
Deficiencies: 0
Jun 18, 2024
Visit Reason
The visit was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.
Findings
No deficiencies were cited during the inspection. The facility was toured, records reviewed, and safety measures such as fire clearance, lighting, temperature, and medication storage were found to be in compliance.
Report Facts
Hospice waiver approved residents: 13
Administrator Certificate expiration: Sep 27, 2024
Residents records reviewed: 7
Staff records reviewed: 6
Staff with current first aid training: 5
Hot water temperature readings: 112.7
Hot water temperature readings: 113
Hot water temperature readings: 115.2
Hot water temperature readings: 114.5
Hallway temperature readings: 76
Hallway temperature readings: 75
Hallway temperature readings: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda L. Fisher | General Manager | Met with Licensing Program Analysts during inspection and toured facility |
| Davinderjit Singh | Health Services Director | Met with Licensing Program Analysts and explained purpose of visit |
| Noel Samonte | Maintenance and Housekeeping Director | Accompanied Licensing Program Analysts during facility tour |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 90
Deficiencies: 0
Jan 4, 2024
Visit Reason
The visit was an unannounced case management follow-up on an incident report and death report received by Community Care Licensing regarding a resident's fall and subsequent death.
Findings
The investigation detailed the resident's fall, hospital discharge, and subsequent death at the facility. No deficiencies were cited during this visit.
Complaint Details
The visit was triggered by an incident report and death report received on 11/10/2023. The resident fell on 11/04/2023, was hospitalized, discharged, and found deceased on 11/06/2023. The cause of death was unknown. The facility provided related incident and service reports. The family will provide the death certificate when available.
Report Facts
Facility capacity: 90
Resident census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda L. Fisher | General Manager | Met with Licensing Program Analyst during visit and provided information about the incident |
| Yelba Havelhorst | Care Director | Met with Licensing Program Analyst during visit and explained purpose of the visit |
| Lori Alexander | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 90
Deficiencies: 0
Jan 4, 2024
Visit Reason
An unannounced Case Management visit was conducted regarding an incident reported on 12/24/2023 involving a resident's wound that was not healing and had spread.
Findings
The investigation found that the resident had a wound that was being monitored and treated by both facility staff and home health agency. Despite ongoing care, the wound was not improving as of 12/18/2023. No deficiencies were issued during the visit.
Complaint Details
The visit was triggered by an unusual incident/injury report about Resident 1's worsening wound on the buttocks, inability to reposition, and related care concerns. The complaint was investigated through staff interviews and review of medical and care documentation.
Report Facts
Facility capacity: 90
Resident census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda L. Fisher | General Manager | Met during visit and provided information about the incident |
| Maria Collado | Health Services Director, LVN | Phoned and arrived to assist with the reported incident |
| Yelba Havelhorst | Care Director | Met during visit and explained purpose of the visit |
| Lori Alexander | Licensing Program Analyst | Conducted the unannounced case management visit |
| Bennett Fong | Licensing Program Manager | Named in report header and signature |
Inspection Report
Census: 75
Capacity: 90
Deficiencies: 1
Aug 1, 2023
Visit Reason
An unannounced Case Management visit was conducted to amend a Deficiency/Plan of Correction cited from the previous visit on 07/31/2023.
Findings
The Licensing Program Analyst reviewed physicians' reports for residents R1 and R2 and addressed a Technical Advisory regarding scissors observed in R2's room on 07/31/2023. An amended report was provided to the facility's General Manager.
Deficiencies (1)
| Description |
|---|
| Technical Advisory, CCR 87309(a), for scissors observed in R2's room on 07/31/2023. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda L. Fisher | General Manager | Met with Licensing Program Analyst during the visit and received amended report. |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Bennett Fong | Licensing Program Manager | Named in the report header. |
Inspection Report
Annual Inspection
Census: 75
Capacity: 90
Deficiencies: 5
Jul 31, 2023
Visit Reason
Unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing regulations and facility safety standards.
Findings
The inspection identified several deficiencies including missing non-skid mats in residents' showers, unlocked disinfectant spray and cleaning chemicals accessible to residents, vitamins and Extra Strength Tylenol stored in residents' rooms, and one staff member missing First Aid certification.
Deficiencies (5)
| Description |
|---|
| Missing non-skid mats in residents' showers located in assisted living and memory care. |
| "Goof Off" Disinfectant Spray unlocked in cabinet located in Laundry Room downstairs. |
| Two bottles of Anti-bacterial All Purpose Cleaner unlocked under kitchen cabinet in Memory Care. |
| Vitamins and Extra Strength Tylenol found in residents' rooms in assisted living. |
| One of five staff missing First Aid certification. |
Report Facts
Capacity: 90
Census: 75
Hospice Care Waiver: 13
Staff reviewed: 5
Resident records reviewed: 5
Plan of Correction Due Date: Aug 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda L. Fisher | Administrator | Facility Administrator mentioned in report |
| Maria Collado | Health Services Director | Met with Licensing Program Analysts during inspection |
| Yelba Havelhorst | Care Director | Accompanied LPAs during facility tour |
| Lori Alexander-Washington | Licensing Program Analyst | Conducted inspection and signed report |
| Bennett Fong | Licensing Program Manager | Supervisor overseeing inspection |
Inspection Report
Census: 57
Capacity: 90
Deficiencies: 1
Aug 23, 2022
Visit Reason
An unannounced Case Management visit was conducted regarding a hospice initiation that was reported to the Community Care Licensing Division (CCLD) on 08/22/2022.
Findings
The facility failed to submit the hospice notification within the required five working days and did not include the date of admission to the facility or the address of the hospice agency. This deficiency was cited under California Code of Regulation, Title 22.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the Department in writing within five working days of the initiation of hospice care services, including the name and date of admission and the name and address of the hospice. | Type B |
Report Facts
Residents admitted to hospice services: 3
Plan of Correction Due Date: Aug 30, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laura Hall | Licensing Program Analyst | Conducted the inspection and signed the report |
| Linda Fisher | General Manager | Met with Licensing Program Analysts during the visit |
| Harpreet Humpal | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Routine
Census: 61
Capacity: 90
Deficiencies: 0
Aug 5, 2022
Visit Reason
The inspection was an unannounced Infection Control Inspection conducted as a required 1-year visit.
Findings
The facility was toured including multiple areas and was found to have sufficient food supplies, posted visitor policies, proper PPE usage, and a mitigation plan with routine screening records. No deficiencies were cited during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maria Collado | Health Services Director | Met with Licensing Program Analyst during the Infection Control Inspection. |
Inspection Report
Original Licensing
Census: 60
Capacity: 90
Deficiencies: 0
May 24, 2021
Visit Reason
An unannounced pre-licensing visit was conducted to evaluate the facility's readiness for licensing and to ensure compliance with regulatory requirements.
Findings
The facility was found to be in compliance with all observed requirements, including proper COVID-19 precautions, safety equipment, and adequate supplies. No deficiencies were noted, and the facility was deemed ready for licensing.
Report Facts
Hot water temperature: 106.5
Perishable food supply: 2
Nonperishable food supply: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daisy Panlilio | Licensing Program Analyst | Conducted the unannounced pre-licensing visit and inspection |
| Luis Olivas | General Manager | Met with Licensing Program Analyst during the visit |
Inspection Report
Census: 60
Capacity: 90
Deficiencies: 0
May 24, 2021
Visit Reason
The visit was a Case Management - Other type, including a Component III presentation during a pre-licensing inspection with the general manager to discuss common deficiencies and Title 22 regulations compliance.
Findings
The Licensing Program Analyst discussed common deficiencies cited for Residential Care Facilities with the general manager and reviewed corrective actions and compliance requirements. The general manager agreed to maintain compliance with Title 22 regulations and shared updated Provider Information Notices with staff and residents.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Olivas | General Manager | Met with during the inspection and discussed compliance and deficiencies. |
Inspection Report
Original Licensing
Capacity: 90
Deficiencies: 0
May 7, 2021
Visit Reason
The visit was conducted as part of the original licensing process for Aegis Living Pleasant Hill facility, including a telephone call with the Community Care Licensing analyst to complete Component II of the licensing application.
Findings
The applicant and administrator successfully completed Component II, demonstrating understanding of Title 22 regulations including facility operation, staff qualifications, program policies, and application document requirements. The applicant was advised to submit required documentation to the licensing office.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rochelle Balancio | Administrator | Administrator participating in licensing application and telephone call |
| Ana De La Cerda | Met with during licensing application telephone call | |
| Julia Kim | Licensing Program Manager | Named as Licensing Program Manager on report |
| Nicole Rouse | Licensing Program Analyst | Named as Licensing Program Analyst on report |
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