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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601101
Report Date: 01/12/2024
Date Signed: 01/12/2024 03:52:13 PM


Document Has Been Signed on 01/12/2024 03:52 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 FRANCISCOFACILITY NUMBER:
415601101
ADMINISTRATOR:CECILIA DAUTHFACILITY TYPE:
740
ADDRESS:2280 GELLERT BLVDTELEPHONE:
(650) 952-6100
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:100CENSUS: 65DATE:
01/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Cecilia DauthTIME COMPLETED:
04:00 PM
NARRATIVE
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During the investigation of complaint #14-AS-20230403164840, a deficiency of the California Code of Regulations, Title 22 was observed. Details follow below, and citation appears on a following page.

This requirement was not met, as clients #1 and #2 were roommates for at least two weeks, as documented by facility's internal billing forms. Client #2 was on hospice since 3/17/23 and passed away on 3/31/23. Conservator of client #1 did not provide written consent for client #1 to share room with hospice client, nor was there any notice given that there would be a roommate. Licensee failed to ensure that client #1 or conservator consented to having roommate who was receiving hospice services, which posed a potential health, safety or personal rights risk to client.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
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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Document Has Been Signed on 01/12/2024 03:52 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2024
Section Cited
CCR
87633(h)(5)

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HOSPICE CARE OF TERMINALLY ILL
For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain...A statement signed by the resident's roommate, if any, or any resident who will share a room with a person who is terminally ill to be accepted or retained ...
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Plan/proof of correction to be submitted to CCLD BY DUE DATE
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indicating his or her acknowledgment that the resident intends to receive hospice care in the facility for the remainder of the resident's life, and the roommate's voluntary agreement to grant access to the shared living space to hospice caregivers, and the resident's support network of family members, friends, clergy, and others. See LIC809.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
LIC809 (FAS) - (06/04)
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