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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201060
Report Date: 08/01/2023
Date Signed: 08/01/2023 09:14:40 PM


Document Has Been Signed on 08/01/2023 09:14 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:AEGIS LIVING PLEASANT HILLFACILITY NUMBER:
079201060
ADMINISTRATOR:LINDA L. FISHERFACILITY TYPE:
740
ADDRESS:1660 OAK PARK BLVDTELEPHONE:
(925) 939-2700
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:90CENSUS: 75DATE:
08/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Linda Fisher, General ManagerTIME COMPLETED:
12:00 PM
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On 08/01/2023 at 10:42 AM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit to amend an Deficiency/POC which was cited from the previous visit on 07/31/2023. LPA met with General Manager, Linda Fisher and explained the purpose of the visit.

LPA received a copy and reviewed R1's and R2's Physicians Reports.

Technical Advisory, CCR 87309(a), for scissors observed by LPA in R2's room on 07/31/2023.

A copy of the amended report was provided to Linda Fisher.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023
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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