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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202830
Report Date: 09/16/2021
Date Signed: 09/16/2021 01:59:30 PM

Document Has Been Signed on 09/16/2021 01:59 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:AEGIS CARE, INC.FACILITY NUMBER:
435202830
ADMINISTRATOR:GHARAKHANIAN, CANDICEFACILITY TYPE:
735
ADDRESS:1060 ORTEGA CIRTELEPHONE:
(408) 461-0330
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
09/16/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:GHARAKHANIAN, CANDICETIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Christine Dolores and Marybeth Donovan arrived unannounced to conduct a pre-licensing visit. LPAs met with Candice Gharakhanian, Administrator.

There is currently residents living at the facility. The facility has an approved fire clearance for 6 capacity and 2 may be non-ambulatory.

LPAs toured the facility inside and outside including the entry point, living room, dining room, kitchen, bedrooms, bathrooms, and patio. Resident rooms were equipped with proper furniture and lighting. Bedding and linens are available to the residents and observed clean. Bathroom was equipped with hygiene supplies and toiletry. Hot water temperature was measured at 115.4 degrees Fahrenheit in hall bathroom. Facility is equipped with cups, plates, utensils, and cooking supplies.

Medications are secured in a locked cabinet in the dining room. LPAs reviewed centrally stored medication records with residents medications. LPAs observed first aid kit with the following supplies: bandages, scissors, tweezers, and thermometer.

LPAs observed sharp objects in a locked box in the kitchen. Cleaning supplies secured in a locked cabinet in the dining room.

LPAs reviewed 6 resident files and 3 staff files. Facility staff are fingerprint cleared and associated to the facility. Resident files all consist of Admission Agreement, Medical Assessment with TB Information, Consent Forms, Needs and Services Plans, Safeguard for Personal Properties and Valuables, and Personal Rights.

Continue on LIC-809C
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: AEGIS CARE, INC.
FACILITY NUMBER: 435202830
VISIT DATE: 09/16/2021
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Staff files all consist of Personal Record, Health Screening with TB Information, First Aid Certification and Training.

Component III is being waived because applicant has been a facility administrator since 2003.

No issues noted during this pre-licensing inspection.

LPAs observed the facility is ready to be licensed. However, this report will be submitted to the Central Application Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

This report was reviewed with Candice Gharakhanian, Administrator and a copy of this report
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC809 (FAS) - (06/04)
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