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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601101
Report Date: 05/07/2021
Date Signed: 05/07/2021 05:13:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 8-3-91
SACRAMENTO, CA 95814
FACILITY NAME:AEGIS LIVING SAN FRANCISCOFACILITY NUMBER:
415601101
ADMINISTRATOR:HOWARD, FAIMAFILI (FILI)FACILITY TYPE:
740
ADDRESS:2280 GELLERT BLVDTELEPHONE:
(650) 242-4154
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:100CENSUS: DATE:
05/07/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:De La Cerda, Ana & Lyons, ChristineTIME COMPLETED:
10:30 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 100
Method: Telephone call with CAB

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB.
Identification of the applicant and administrator was verified by correctly answering identity
verification question. During COMP II, applicant and administrator confirmed the
understanding of Title 22. Component II was successfully completed. Applicant has been
advised to transmit signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of
following areas:
1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting
incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
7. Application document review and technical assistance: Criminal record clearance,
Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial
verification, Pre-licensing inspection, Compliance history, Control of property
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Nicole RouseTELEPHONE: (916) 657-2600
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021
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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