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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201063
Report Date: 09/13/2024
Date Signed: 09/13/2024 03:54:02 PM

Document Has Been Signed on 09/13/2024 03:54 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/
DIRECTOR:		POON, EMILYFACILITY TYPE:
740
ADDRESS:36281 FREMONT BLVDTELEPHONE:
(949) 488-2669
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 85CENSUS: 76DATE:
09/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Emily Poon- Executive Director TIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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On this day 09/13/2024 at 2:10 pm, Licensing Program Analysts (LPAs) Patricia Manalo and Luisa Fontanilla arrived to the facility to conduct a case management visit regarding a incident report and met with Executive Director, Emily Poon and explained the purpose of the visit.

During the visit, LPAs interviewed R1 and S1 by obtaining an interpreter service. LPAs attempted to interview R1. However, due to R1's dementia, LPAs were unable to obtain relevant information. LPAs interviewed S1 and S1 demonstrated to LPAs how the incident occurred.

No deficiencies were cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2024
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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