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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201063
Report Date: 09/07/2023
Date Signed: 09/07/2023 09:13:43 AM


Document Has Been Signed on 09/07/2023 09:13 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
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: 73DATE:
09/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Gigi Tamayo, Registered Nurse (RN)TIME COMPLETED:
09:20 AM
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On 9/7/2023 starting at 9:05 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a case management visit to deliver amended report originally dated 6/9/2023. LPA met with Gigi Tamayo, RN and informed her the reason for visit.

During visit, LPA obtained original report dated 6/9/2023 from RN.


No deficiencies are being cited on this date.


Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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