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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 03:36:10 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Luis Olivas, General ManagerTIME COMPLETED:
03:40 PM
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On 05/24/21 at 3PM, a Component III presentation was also completed by LPA D Panlilio during the pre-licensing inspection with the general manager (GM).

LPA discussed the most common deficiencies cited for Residential Care Facilities (RCFEs) with GM. LPA discussed with GM the CA Title 22 regulations sections for each deficiency and corrective actions needed to clear citations as wells as how to avoid them.

GM agreed to stay in compliance with Title 22 regulations. He stated that he attends the CCLDs & CALA informational calls offered and has shared updated Provider Information Notices (PINs) with staff, residents and authorized representatives.
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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