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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601374
Report Date: 10/06/2022
Date Signed: 10/06/2022 02:06:53 PM


Document Has Been Signed on 10/06/2022 02:06 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 ASSISTED LIVING OF FREMONTFACILITY NUMBER:
015601374
ADMINISTRATOR:SHASHI K MADAHARFACILITY TYPE:
740
ADDRESS:3850 WALNUT AVENUETELEPHONE:
(510) 739-1515
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:110CENSUS: 81DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Shashi K Madahar, Health Services DirectorTIME COMPLETED:
02:10 PM
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On today's date, 10/6/2022, at 12:55 PM, Licensing Program Analyst (LPAs) L. Fici and C. Lin arrived unannounced to conduct Infection Control Inspection. LPAs met with Shashi K Madahar, Health Services Director (HSD) and explained the purpose of the visit.

During the inspection, LPAs toured facility including but not limited to common areas, hand washing stations, bedrooms, bathrooms, kitchen and courtyard. LPAs observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPAs observed PPE's are plentiful. Food and paper supplies are sufficient. Hand sanitizer is provided at facility entrance. LPAs observed water temperature in the memory care unit bathroom measured at 113.2 degrees F. Fire extinguisher was last serviced on 8/12/2022. LPAs observed facility passages inside and out are free of obstruction. First aid kit was observed to be complete. Smoke and carbon monoxide detectors were observed and maintained. Common areas are disinfected 3 or more times a day.

During record review, LPAs observed facility has a copy of Infection Control Plan and emergency disaster plan on file.

No deficiencies cited during visit.

Exit interview conducted with Health Services Director and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
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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