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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201063
Report Date: 07/20/2022
Date Signed: 07/20/2022 04:15:54 PM


Document Has Been Signed on 07/20/2022 04:15 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: 97DATE:
07/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Cathy ZhouTIME COMPLETED:
04:30 PM
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On 7/20/22 at 10:40AM, Licensing Program Analysts (LPAs) J. Sampair and L. Fici arrived unannounced to conduct a case management visit concerning a 7/3/22 incident report. The LPAs met with Health and Services Director, Cathy Zhou.

In the 7/3/22 report, Staff 5 (S5) was accused by Resident 2 (R2) of hitting their spouse, Resident 1 (R1) on 7/2/22. Facility notified Ombudsman, but not the police. During this case management visit, the LPAs reviewed records and conducted interviews of residents and staff.

The record review of S5 found no previous complaints and up-to-date training. During the interviews of three (3) staff members and one (1) resident, though neither were R1 or R2 due to their current condition, the LPAs found concurrence with the findings of the internal investigation that there was "no evidence" that S5 had hit R2.

S5 returned to work on 7/5/22.

LPAs collected the following documents: staff roster, resident roster, and a copy of internal investigation.

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: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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