<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601101
Report Date: 06/30/2023
Date Signed: 07/03/2023 09:39:02 AM


Document Has Been Signed on 07/03/2023 09:39 AM - 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 FRANCISCOFACILITY NUMBER:
415601101
ADMINISTRATOR:CECILIA DAUTHFACILITY TYPE:
740
ADDRESS:2280 GELLERT BLVDTELEPHONE:
(650) 952-6100
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:100CENSUS: 61DATE:
06/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Cecilia DauthTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Marketing Director Gina Avalos and Administrator Cecilia Dauth followed after. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including a random sample of resident rooms, common areas & kitchen area. The indoor and outdoor passageways were free of obstruction. LPA observed some residents were in the activity room doing some exercises, there were also residents in the living room area that are resting. Hot water was also tested in the bathrooms and the temperature was 110 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid floors. Body of water, a fountain in the courtyard is barricaded so it’s not accessible to residents. LPA checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency drills are logged and done every quarter.

LPA reviewed 4 resident records and 4 staff record. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic 20hr requirement. Facility has a certified administrator on site with complete certification and training requirements. Facility accepts hospice residents and are in compliance with the required waiver requirements.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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
VISIT DATE: 06/30/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA interviewed 4 residents and 4 staff members. All staff are very competent with regards to the care of the residents.

LPA requested licensee to submit the following and was received in the facility at 6/30/2023:

LIC 500 Personnel Report
Proof for renewal of Administrator Certificate

No deficiencies are cited at this time. Report is reviewed with Administrator and a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2