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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201060
Report Date: 06/18/2024
Date Signed: 06/18/2024 03:41:42 PM


Document Has Been Signed on 06/18/2024 03:41 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: 72DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Linda Fisher, General ManagerTIME COMPLETED:
04:00 PM
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On 06/18/2024 at 10:45 AM, Licensing Program Analysts (LPAs) L. Alexander and L. Holmes arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Health Services Director, Davinderjit Singh and explained the purpose of the visit. General Manager (GM), Linda Fisher, arrived shortly after. The facility’s fire clearance was approved for capacity of non-ambulatory 90 (ninety) residents. In which 5 (five) may be bedridden. Hospice waiver approved for 13 (thirteen) residents. Administrator Certificate #6049700740 expires 09/27/2024.

LPAs toured the facility with Maintenance and Housekeeping Director, Noel Samonte and Linda Fisher (GM) including but not limited to 6 (six) residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 76, 75 and 71 degrees F. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 112.7, 113.0, 115.2 and 114.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care.

LPAs reviewed 7 residents records. LPAs reviewed 6 staff records and 5 of 6 have current first aid training and associated to the facility.

LIC809-C Continued...
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HILL
FACILITY NUMBER: 079201060
VISIT DATE: 06/18/2024
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LIC809-C Continued...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/25/2024:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
Liability Insurance

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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