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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601424
Report Date: 12/14/2023
Date Signed: 12/14/2023 11:39:50 AM


Document Has Been Signed on 12/14/2023 11:39 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 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: 81DATE:
12/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Amria Angeles Sticka, Executive DirectorTIME COMPLETED:
12:00 PM
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On 12/14/2023 Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced case management visit regarding a SOC 341 self-reported incident that occurred on 12/7/23. LPA spoke with Amria Angeles Sticka, Executive Director and explained the purpose of the visit.

LPA received an SOC 341 self-reported regrading a resident hitting another resident well in the community. LPA interviewed S1 regrading the incident. S1 stated that the situation has been resolved. S1 spoke with the victim family members and explained the situation. R1 was being treated for UTI and now is calmed. S1 had the following plan implement.

- R1 was being evaluated by the physician.
- Internal investigation of the caused of R1 irritation.
- R1 was assigned a one on one after that incident.
- LVN did an assessment on R2 for any injury (found no injury)

LPA reviewed:

- Physician Notification
- PCP notification of R1 behavior
- Change in medication.
- S1 Communication between R1 family member regrading R1 change in behavior.
- S1 Communication with R2 family member


No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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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