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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202830
Report Date: 10/24/2024
Date Signed: 10/24/2024 12:06:15 PM

Document Has Been Signed on 10/24/2024 12:06 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/
DIRECTOR:		GHARAKHANIAN, CANDICEFACILITY TYPE:
735
ADDRESS:1060 ORTEGA CIRTELEPHONE:
(408) 461-0330
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Candice GharakhanianTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
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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 (ADM), Candice Gharakhanian.

During visit, LPA toured the facility with staff 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. Facility temperature maintained at 71 degrees Fahrenheit. Facility has carbon monoxide detector present in the hallway. Fire extinguisher last serviced on 07/25/2024.

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 0 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: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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 10/24/2024 12:06 PM - It Cannot Be Edited


Created By: Christine Dolores On 10/24/2024 at 11:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: AEGIS CARE, INC.
FACILITY NUMBER: 435202830

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above wherein the hot water temperature was observed maintained at 129.9 degrees F and 132.2 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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Administrator turned down the hot water temperature. LPA observed the hot water temperature is maintained at 115.7 degrees F and 118.0 degrees F. Deficiency cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


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: 10/24/2024
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Bathrooms supplied with hygiene products, paper supplies, and hand washing signs. LPA tested the hot water temperature in bathroom #1 located in the hallway using a thermometer which measured at 129.9 degrees F. LPA observed the facility's hot water temperature log and observed the hot water temperature was recorded at 119 degrees F on 10/23/2024. Staff used the facility's thermometer to measure the hot water temperature, which measured at 129 degrees F. Bathroom #2 located inside bedroom #1 hot water temperature maintained at 132.2 degrees F. During visit, ADM lowered the hot water temperature. LPA measured the hot water temperature in bathroom #1 maintained at 115.7 degrees F and bathroom #2 maintained at 118.0 degrees F. 3 resident bedrooms equipped with beds, linens, closet space, night stand, adequate lighting, and personal items.

Facility has an emergency disaster plan. LPA advised to update the exit doors on the emergency disaster plan to include the exit doors in bedroom #1 and the laundry room. LPA observed a bin filled with emergency supplies. Facility conducts emergency disaster drills monthly. The last drill was conducted in October 2024.

3 residents files were reviewed. 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. 3 residents centrally stored medications and P&I money were inspected and observed maintained. 1 resident observed with an updated restricted health care condition plan and staff training plan.

3 staff files were reviewed. Staff files contained a 1st aid certification, fingerprint clearance, LIC501, LIC503, TB information, and 2024 training.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator Candice Gharakhanian and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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