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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601374
Report Date: 10/28/2024
Date Signed: 10/28/2024 03:47:31 PM

Document Has Been Signed on 10/28/2024 03:47 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AEGIS ASSISTED LIVING OF FREMONTFACILITY NUMBER:
015601374
ADMINISTRATOR/
DIRECTOR:		TURNER, RYANFACILITY TYPE:
740
ADDRESS:3850 WALNUT AVENUETELEPHONE:
(510) 739-1515
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 110TOTAL ENROLLED CHILDREN: 0CENSUS: 68DATE:
10/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Leslie Ibo, Health Services Director TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 10/28/2024 at 9:00AM, Licensing Program Analysts (LPAs) P. Manalo and J. Clancy-Czuleger arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Health Services Director, Leslie Ibo and explained the purpose of the visit. Administrator, Ryan Turner, arrived shortly after.

LPAs toured the facility with Administrator, Ryan Turner, including but not limited to 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. 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 115 and 114.1 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars with 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.

At 9:45 AM, LPAs reviewed 8 residents records. At 10:45 AM, LPAs reviewed 8 staff records and 8 of 8 are associated to the facility.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was observed last serviced on 08/28/2024 and kitchen fire extinguisher was last serviced on 08/28/2024. First aid kit was observed to be complete.

Continue LIC809C...
Yvonne Flores-LariosTELEPHONE: (510) 286-4201
Patricia ManaloTELEPHONE: (916) 432-7785
DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AEGIS ASSISTED LIVING OF FREMONT
FACILITY NUMBER: 015601374
VISIT DATE: 10/28/2024
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/04/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Patricia ManaloTELEPHONE: (916) 432-7785
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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