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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201063
Report Date: 06/06/2023
Date Signed: 06/06/2023 11:58:17 AM


Document Has Been Signed on 06/06/2023 11:58 AM - 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: 73DATE:
06/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Gigi Tamayo (RN)TIME COMPLETED:
12:05 PM
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On 6/6/2023 at 10:20 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a case management visit regarding an incident report received on 5/20/2023. LPA met with Gigi Tamayo (RN) and explained the purpose of the visit.

Incident report dated for 5/18/2023 revealed that Resident 1 (R1) reported ingesting calligraphy ink during facilities activity. RN stated that resident was doing calligraphy as part of resident’s activity in the facility. S1 informed RN that the resident had black ink all over her hands and mouth. S1 observed resident's hands and mouth with black ink, S1 asked S2 to help clean resident’s hands and mouth, and S3 informed RN about the incident. Facility staff took R1's vital signs and assessed her if R1 had any pain from ink. Facility called 911 for further evaluation. R1's representative was notified, poison control was notified and RN stated that poison control could not find much information if the ink was harmful to ingest. R1 returned to the facility on 5/18/2023 with no concerning health issues.

LPA collected the following documents: After visit summary, and Physician's visit report form.

No deficiencies cited during visit.

Exit interview conducted with RN and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2023
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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