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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601374
Report Date: 12/06/2024
Date Signed: 12/06/2024 10:09:06 AM

Document Has Been Signed on 12/06/2024 10:09 AM - 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: 65DATE:
12/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Ryan Turner, Executive Director TIME VISIT/
INSPECTION COMPLETED:
10:20 AM
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On 12/06/2024 at 8:55 AM Licensing Program Analysts (LPAs) P.Manalo and L. Fontanilla conducted an unannounced Case Management visit regarding a self-reported abuse that occured on 11/29/2024. Health Services Director self-reported the incident on 12/05/2024. LPAs met with Executive Director, Ryan Turner, and explained the purpose of the visit.

LPAs interviewed R1, R2, Executive Director, and Health Services Director regarding the incident. R1 has dementia diagnosis and lives in the Memory Care Unit. R2 stated that S1 pulled R1's leg while R1 was in bed.

LPAs interviewed Executive Director and Health Services Director who stated that S1 was terminated on 12/05/2024 and has been removed from the facility roster.

LPAs obtained the following documents such as R1's Physician's Report, S1's Termination Paper, S1's Employee Files, Staff Roster, and Resident Report.

No deficiencies cited during visit. Exit interview was conducted with Executive Director and a copy of this report was provided.
Yvonne Flores-LariosTELEPHONE: (510) 286-4201
Patricia ManaloTELEPHONE: (916) 432-7785
DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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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