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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920145
Report Date: 05/23/2024
Date Signed: 05/23/2024 02:15:14 PM


Document Has Been Signed on 05/23/2024 02:15 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:AEGIS SENIOR RESIDENCEFACILITY NUMBER:
345920145
ADMINISTRATOR:KONTSEMAL, ANASTASIIAFACILITY TYPE:
740
ADDRESS:3200 LA MADERA WAYTELEPHONE:
(888) 493-1459
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 0DATE:
05/23/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator- Anastasiia KontsemalTIME COMPLETED:
02:20 PM
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On 05/23/24 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility announced to conduct a pre-licensing inspection utilizing the pre-inspection tool. LPA met with Administrator Anastasiia Kontsemal and explained the purpose of the visit.

LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to: six (6) residents private bedrooms, three (3) bathrooms, staff room, garage, laundry room, backyard and common areas. LPA observed resident bedrooms to have the proper furniture of comfortable bed, night stand, dresser, lamp and chair.

LPA observed the facility to have a proper storage for medications, toxins and sharps which is locked and inaccessible. LPA observed facility to have ample supply of personal hygiene, linen, and non-perishable foods. LPA observed the exterior of the facility to be free of obstruction. The temperature inside the facility during the time of inspection was 75 degrees Fahrenheit. The hot water temperature was measured at 105.1 degrees Fahrenheit which is within the required range. LPA observed the facility to have the required posters of Community Care Licensing Division and Long Term Care Ombudsman. LPA observed fire extinguisher located in the family room to be last serviced on 03/05/24. LPA observed smoke and carbon monoxide detectors to be operable. First aid kit is maintained and ready for use.

LPA and Administrator completed the inspection tool and Comp III. Pre-Licensing completed and no deficiencies was observed. LPA provided Administrator a copy of LIC 311F. Administrator will inform LPA once they have their first resident.

LPA informed Applicant facility is not licensed until Applicant is informed by Centralized Application Bureau Analyst with a copy of facility license.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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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