<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600581
Report Date: 06/16/2021
Date Signed: 06/16/2021 12:27:05 PM

Document Has Been Signed on 06/16/2021 12:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AEGIS GARDENSFACILITY NUMBER:
015600581
ADMINISTRATOR:POON, EMILYFACILITY TYPE:
740
ADDRESS:36281 FREMONT BLVDTELEPHONE:
(510) 739-0909
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 85CENSUS: 76DATE:
06/16/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Rachel Chan and Cathy ZhouTIME COMPLETED:
12:40 PM
NARRATIVE
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
On 06/16/2021 at 8:50am, Licensing Program Analysts (LPAs) Allison O'Hollaren and Lizette Francisco conducted a case management while at the facility for another matter. LPAs met with Business Office Manager Rachel Chan and House Service Director Cathy Zhou.

LPAs observed cleaning supplies unlocked in R3's bedroom.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/16/2021 12:27 PM - It Cannot Be Edited


Created By: Allison O'Hollaren On 06/16/2021 at 12:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: AEGIS GARDENS
FACILITY NUMBER: 015600581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2021
Section Cited
CCR
87309(a)

1
2
3
4
5
6
7
87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
1
2
3
4
5
6
7
By POC date, facility will store cleaning supplies in locked cabinet.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above. LPAs observed cleaning supplies in R3's bedroom which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Allison O'Hollaren
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2