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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201063
Report Date: 07/19/2023
Date Signed: 07/19/2023 02:56:30 PM


Document Has Been Signed on 07/19/2023 02:56 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 GARDENSFACILITY NUMBER:
019201063
ADMINISTRATOR:POON, EMILYFACILITY TYPE:
740
ADDRESS:36281 FREMONT BLVDTELEPHONE:
(949) 488-2669
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:85CENSUS: DATE:
07/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Gigi Tamayo, RNTIME COMPLETED:
01:25 PM
NARRATIVE
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On 7/19/2023 at 1:08 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a Case Management. LPA met with Gigi Tamayo, Registered nurse (RN).

When LPA L. Fici opened a 10-day initial complaint visit (15-AS-20230711115733) on 7/19/2023. R1 was hospitalized on 1/30/2023, and returned to the community on 2/4/2023. LPA observed R1 with a restricted health condition and reviewed R1's file and observed facility did not request an exemption before re-admitting R1 with a restricted health condition. S1 stated that the facility did not request an exemption.

The following deficiency was observed:

- On 7/19/2023, LPA reviewed R1's file and did not observed an exemption for a restricted health condition.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.


Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
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 2


Document Has Been Signed on 07/19/2023 02:56 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: AEGIS GARDENS
FACILITY NUMBER: 019201063

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
07/26/2023
Section Cited
CCR
87612(a)(2)

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87612(a)(2) Restricted Health Conditions:
(a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services: (2) Catheter care as specified in Section 87623.
This requirement is not met as evidenced by:
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Administrator agreed to request an exception for R1 for a restricted health condition to CCL by POC due date.
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Based on observation, and record review, the licensee did not comply with the section cited above by not submitting a exception for a restricted health condition for R1, which poses/posed 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2