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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601101
Report Date: 11/30/2023
Date Signed: 12/01/2023 08:20:58 AM


Document Has Been Signed on 12/01/2023 08:20 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
SAN BRUNO RO, 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: 62DATE:
11/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Cecilia Dauth & Hayley RagasaTIME COMPLETED:
03:30 PM
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On 11/30/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management for an incident report. LPA met with Administrator, Cecilia Dauth & Resident Wellness Director Hayley Ragasa and explained the purpose of today's visit.

On 11/27/23, Licensing received a report submitted by the facility with regards to a resident (R1) needing assistance after being found on the floor face down. 911 was called and it was noted that resident had strong alcohol breath.

Based on interview with Administrator and Resident Wellness Director, R1 is allowed to have alcohol and they are not able to regulate it unless there is a doctors order and responsible party also gave consent for R1 to drink. Responsible party and Doctor were made aware of the incident. R1 was back in the facility on the same day after tests show negative findings. Care Plan will be updated accordingly.

Facility has followed regulations regarding residents personal rights.

No citations are issued at this time.

Report is reviewed and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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