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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415601101
Report Date:
04/09/2024
Date Signed:
04/09/2024 10:00:21 PM
Document Has Been Signed on
04/09/2024 10:00 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
AEGIS LIVING SAN FRANCISCO
FACILITY NUMBER:
415601101
ADMINISTRATOR:
CECILIA DAUTH
FACILITY TYPE:
740
ADDRESS:
2280 GELLERT BLVD
TELEPHONE:
(650) 952-6100
CITY:
SOUTH SAN FRANCISCO
STATE:
CA
ZIP CODE:
94080
CAPACITY:
100
CENSUS:
66
DATE:
04/09/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME BEGAN:
03:00 PM
MET WITH:
Cecilia Dauth
TIME COMPLETED:
04:00 PM
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On 4/9/24 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management visit. LPA met with Administrator Cecila Dauth explained purpose of today's visit.
LPA received a report on 3/26/24 about an incident that happened on 3/25/24.
A referral partner witnessed an altercation between resident (R1) and a family member (F1) in the parking lot. Two person witnessed an elderly slapped on the left cheek and was shoved by force inside a private car.
LPA interviewed Administrator (ADM) Cecilia Dauth and Health Services Director (HSD) Hayley Ragasa. Both mentioned that they didn't witness what happened. HSD observed the resident when R1 went back to the facility and there were no apparent injuries. R1 was observed to be in good condition upon returning.
No deficiencies cited today. Report is reviewed and copy is provided.
SUPERVISOR'S NAME:
April Cowan
TELEPHONE:
(650) 266-8865
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
04/09/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/09/2024
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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