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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601374
Report Date: 12/30/2022
Date Signed: 12/30/2022 03:26:48 PM


Document Has Been Signed on 12/30/2022 03:26 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:AEGIS ASSISTED LIVING OF FREMONTFACILITY NUMBER:
015601374
ADMINISTRATOR:PAUL H SHEPODDFACILITY TYPE:
740
ADDRESS:3850 WALNUT AVENUETELEPHONE:
(510) 739-1515
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:110CENSUS: 98DATE:
12/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:PAUL H SHEPODDTIME COMPLETED:
03:30 PM
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On 12/30/2022, while at the facility for another reason, Licensing program analysts (LPAs) L. Fici And J. Clancy-Czuleger conducted a case management about an incident that the LPA was informed about. LPA confirmed the incident occurred and the administrator attempted to fax it to CCL. LPA discussed with administrator the reporting requirements.

No deficiency cited during visit.

Exit interview conducted with administrator, and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon FiciTELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2022
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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