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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201063
Report Date: 12/30/2021
Date Signed: 12/30/2021 03:25:36 PM

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:
019201063
ADMINISTRATOR:POON, EMILYFACILITY TYPE:
740
ADDRESS:36281 FREMONT BLVDTELEPHONE:
(949) 488-2669
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:85CENSUS: 98DATE:
12/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Cathy Zhou, Health and Services Director and Emily Poon, General ManagerTIME COMPLETED:
03:25 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 12/30/2021 at 1:40PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a case management visit regarding an incident report received on 12/28/2021. LPA met with Health and Services Director, Cathy Zhou and Emily Poon, General Manager.

Incident report dated 12/28/2021 revealed that Resident 1 (R1) reported abuse from Staff 5 (S5). Facility notified law enforcement and R1's responsible party.

LPA interviewed three (3) of four (4) staff. LPA was not able to interview Resident 1 (R1) due to diagnosis. Interview with Staff 1 (S1) revealed that S5 was the caregiver for R1 on the day of the incident. R1 was being assisted by S5 in the bathroom when the incident occurred. R1 reported the incident to Staff (S4). S4 reported the incident to S1. S5 was suspended immediately and after the investigation was terminated on 12/28/2021. Facility will be conducting an abuse training for all staff on 1/5/2022.

LPA collected the following documents: Staff roster, Resident roster, and training documents for S5.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
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 1