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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601424
Report Date: 01/26/2024
Date Signed: 01/26/2024 03:36:59 PM


Document Has Been Signed on 01/26/2024 03:36 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 ASSISTED LIVING OF MORAGAFACILITY NUMBER:
075601424
ADMINISTRATOR:MARIA ANGELES STICKAFACILITY TYPE:
740
ADDRESS:950 COUNTRY CLUB DRIVETELEPHONE:
(925) 377-7900
CITY:MORAGASTATE: CAZIP CODE:
94556
CAPACITY:100CENSUS: 64DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Angela Sticka, Administrator
Won Suk Choi, Co-Administrator		TIME COMPLETED:
04:30 PM
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On 01/26/24 at 12PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with co-administrator (Co-ADM) and explained the purpose of the visit. Co-ADM has a current administrator certificate # 6041047740 which expires 06/15/2024.

At 1:30PM, LPA toured the facility with Co-ADM including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. An electronic sign-in policy, digital scanner temperature device, additional face masks and hand sanitizers were observed at the front desk screening station. LPA observed 2 memory care units located on the first floor with 24 memory care residents. LPA also observed 40 assisted living residents located on the second floor.

Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 72 deg F. Hot water temperature was measured at 118 deg F.

Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 5 staff and 5 resident files. LPA also conducted 5 staff and 5 resident interviews during visit.

Continue on next page, LIC 9099-C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: AEGIS ASSISTED LIVING OF MORAGA
FACILITY NUMBER: 075601424
VISIT DATE: 01/26/2024
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At 3:45PM, LPA obtained updated copies of the following documents for facility file:
 LIC500- Personnel Report
 Residents Roster
 LIC308- Designation of Facility Responsibility
 LIC610E- Emergency/Disaster Plan including infection control plans
 Evidence of Liability Insurance

No deficiencies observed during visit.

Exit interview conducted and a copy of the report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024
LIC809 (FAS) - (06/04)
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