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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415601101
Report Date:
06/09/2023
Date Signed:
06/09/2023 12:47:47 PM
Document Has Been Signed on
06/09/2023 12:47 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
SF COASTAL AC/SC
,
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:
84
DATE:
06/09/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
12:30 PM
MET WITH:
David Shaw
TIME COMPLETED:
01:00 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management visit to deliver an amended complaint report. LPA met with David Shaw business office manager during today's visit.
LPA explained the amended report delivery and the reason it was amended. He confirmed that he understood the amended report.
No citations issued.
Report reviewed with David.
SUPERVISOR'S NAME:
Cara Smith
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Jaime Vado
TELEPHONE:
(559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE:
06/09/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/09/2023
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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