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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201060
Report Date: 05/24/2021
Date Signed: 05/24/2021 03:35:06 PM

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 LIVING PLEASANT HILLFACILITY NUMBER:
079201060
ADMINISTRATOR:BALANCIO, ROCHELLEFACILITY TYPE:
740
ADDRESS:1660 OAK PARK BOULEVARDTELEPHONE:
(915) 939-2700
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:90CENSUS: 60DATE:
05/24/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Luis Olivas, General ManagerTIME COMPLETED:
03:05 PM
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On 05/24/21 at 2PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced pre-licensing visit and met with the general manager (GM). LPA explained the reason for the visit. LPA observed all staff wearing face masks at the facility. A COVID-19 screening station with electronic visitor's log, temperature probe and hand sanitizer were observed by the front entrance.

LPA along with GM toured the facility inside and outside including but not limited to resident's bedrooms, bathrooms, dining room, common living areas, kitchen, and outside patios. There is sufficient lighting around the facility. Resident's rooms were equipped with the proper furniture and lighting. Resident's rooms had proper bedding and linens. Bathrooms were equipped with grab bars, nonskid mats, and hygiene items. Living room is equipped with the proper furniture for the residents. Communal dining areas had dining tables and chairs distanced 6 feet apart. All toxins and sharp objects were locked. Passageways and hallways were free of obstruction. Fire extinguishers were last inspected on 10/23/2020 and are throughout the facility. Smoke detectors and Carbon Monoxide detectors were observed operational. Medication room cabinets were locked and first aid kit was complete. All exit doors in the facility are equipped with auditory signals. Hot water temperature was measured at 106.5 degrees Fahrenheit. LPA observed sufficient perishable (2 days) and nonperishable (3 weeks supply) in the kitchen area. LPA observed the emergency/disaster plan, State License, residents' personal rights, rights to councit. complaint and ombudsman posters displayed in common areas.

LPA observed no deficiencies during this visit and that the facility is ready to be licensed. This report will be submitted to the Central Applications Branch (CAB) and a final review of the application will be conducted. This facility is subject to the final approval by CAB. Additional requirements may still be required. Exit interview conducted and a copy of this report provided to GM.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
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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