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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202830
Report Date: 10/12/2023
Date Signed: 10/12/2023 03:08:49 PM

Document Has Been Signed on 10/12/2023 03:08 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
CENTRAL COAST CR/RES, 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:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:GHARAKHANIAN, CANDICETIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Administrator, Candice Gharakhanian.

During visit, LPA toured the facility with DSP to include the entrance, dining room, living room, kitchen, resident bedrooms, bathrooms, garage, and backyard. LPA observed a shed at the side of the facility. Licensee did not have a key to the shed and states they only store gardening tools in the shed.

All fire exit routes are free and clear of obstruction. All present staff are fingerprint cleared and associated to the facility. LPA observed a camera in the dining room and kitchen area which does not have audio component.

Upon entrance, the facility has a visitor sign-in sheet. Visitation policy posted at the front door along with the facility license, personal rights form, and COVID-19 related posters. Facility temperature maintained at 71 degrees Fahrenheit. Facility has carbon monoxide detector present. Fire extinguisher last serviced on 07/26/2023.

Facility's fireplace observed screened. Medication, disinfectants, and cleaning solutions observed locked. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 44 degrees Fahrenheit. Freezer temperature maintained at -1 degree Fahrenheit. Kitchen is equipped with clean plates, bowls, cups, and utensils. Trash bin with lid observed in the kitchen. Facility has a weekly menu and monthly activities calendar observed posted. During visit, LPA observed residents participating in activities.

SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: AEGIS CARE, INC.
FACILITY NUMBER: 435202830
VISIT DATE: 10/12/2023
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3 out of 3 resident bedrooms observed with furniture to include a bed, adequate lighting, dressers, closet, and night-stands. Bathrooms supplied with hygiene products, paper supplies, and hand washing signs. LPA tested the hot water temperature which measured at 128 degrees Fahrenheit. Licensee tested the hot water temperature using the facility's thermometer with LPA present, which measured the hot water temperature at 110 degrees Fahrenheit. Facility checks and documents the hot water temperature weekly. The hot water temperature was monitored between 106 - 116 between 08/18/23 - 10/09/23. Administrator plans to purchase a new water thermometer.

Facility has an updated infection control plan. Facility staff were provided training on infection control on 09/26/2023. Facility has complete Personal Protective Equipment (PPE) supplies to include gowns, shields, gloves, masks, N95 masks, hand sanitizer, and disinfectant wipes. LPA reviewed the infection control procedures with the staff.

Facility has an updated emergency disaster plan. LPA observed flashlights and batteries. Facility has a box of resident's to-go bag for emergencies. Staff has conducted emergency disaster drills quarterly. The last drill was conducted on 09/14/2023.

3 residents files (R1 - R3) were reviewed. 3 out of 3 residents files contained an admission agreement, medical assessment, TB result, appraisal/needs and services plan, personal rights form, and safeguard of personal property and valuables form. R1 - R3's centrally stored medications and P&I money were inspected and observed maintained.

3 staff files (S1 - S3) were reviewed. 3 out of 3 staff files contained an updated 1st aid certification, fingerprint clearance, LIC501, LIC503, TB information, LIC9052, and 2023 training.

LPA interviewed 3 residents and 3 staff members.

The following documents were obtained during visit to include the LIC500 and liability insurance.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator Candice Gharakhanian and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC809 (FAS) - (06/04)
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