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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201063
Report Date: 06/09/2023
Date Signed: 06/09/2023 03:33:04 PM


Document Has Been Signed on 06/09/2023 03:33 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:
019201063
ADMINISTRATOR:POON, EMILYFACILITY TYPE:
740
ADDRESS:36281 FREMONT BLVDTELEPHONE:
(949) 488-2669
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:85CENSUS: 72DATE:
06/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Gigi Tamayo, RNTIME COMPLETED:
03:40 PM
NARRATIVE
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During the course of investigation of a complaint (15-AS-20230608092900), Licensing Program Analyst (LPA) L. Fici learned that resident (R1) sustained a fall on 10/16/2022, 12/20/2022, and 5/9/2023. Review of records revealed the facility did not submit incident reports to CCL on a timely manner.

LPA discussed with Gigi Tamayo, RN, Emily Poon, Administrator, and Angel Lee, Director of operations, the above incidents, and Title 22 Reporting Requirement.

Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12-month period may result in civil penalty.



Exit interview conducted with RN, and a copy of this report given along with appeal rights.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
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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Document Has Been Signed on 06/09/2023 03:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: AEGIS GARDENS
FACILITY NUMBER: 019201063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
06/16/2023
Section Cited
CCR
87211(a)(1)

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87211(a)(1) Reporting Requirements:(a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...
This requirement is not met as evidenced by:
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Adminisatror agreed to read and understand section 87211(a)(1)- Reporting Requirements, and to submit a signed self-certification to CCL by POC due date.
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Based on interview, the licensee did not comply with the section cited above by not submitting incident reports (Lic624s) to CCL regarding R1's falls which poses a potential health, safety or personal rights risk to persons in care.
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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-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2023
LIC809 (FAS) - (06/04)
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