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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202706
Report Date: 03/10/2022
Date Signed: 03/10/2022 03:23:08 PM


Document Has Been Signed on 03/10/2022 03:23 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 ASSISTED LIVING OF APTOSFACILITY NUMBER:
445202706
ADMINISTRATOR:GALVAN, GRISELDAFACILITY TYPE:
740
ADDRESS:125 HEATHER TERRACETELEPHONE:
(831) 684-2700
CITY:APTOSSTATE: CAZIP CODE:
95003
CAPACITY:100CENSUS: DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Griselda GalvanTIME COMPLETED:
03:30 PM
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 03/10/2022. LPA met with facility administrator Griselda Galvan (Admin) and toured the facility.

Facility Mitigation plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. Fire extinguishers observed to be inspected in April 2021. Water temperature noted to be between 100*F and 110*F across 8 resident rooms.

Facility observed to have designated entry point. Staff took LPA's temperature and screened for symptoms. Facility observed to have a thirty day supply of PPE on the premises. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas. All bathrooms observed to have had lidded trash cans.

During tour of facility kitchen, a small layer of water was observed to be on the ground. Admin stated that they were not sure what the problem was yet, as it had just occurred that morning, but speculated that drains on the floor were clogged. Admin stated that an appointment had been made for a plumber to inspect the issue that day.

No deficiencies cited during today's visit. Advisory note issued. This report was reviewed with facility Administrator Griselda Galvan and a copy of the signed report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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