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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202706
Report Date: 03/28/2023
Date Signed: 03/30/2023 10:08:20 AM


Document Has Been Signed on 03/30/2023 10:08 AM - 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 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:
03/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Griselda GalvanTIME COMPLETED:
04:49 PM
NARRATIVE
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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 03/28/2023 at 11:02am. LPA met with facility Administrator Griselda Galvan (Admin).

LPA toured the facility, including entryway, common room, dining room, kitchen, laundry room, 10 bedrooms, 12 bathrooms, medicine room, and activities room. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated. All residents and staff have received their booster shots as well.

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. Facility water temperature measured at 119.4*F. 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 extinguisher observed to be inspected in October 2022. Smoke/carbon monoxide detectors tested and observed to be operational.

LPA interviewed 10 facility residents and 6 facility staff. 6 out of 10 residents interviewed claimed to be satisfied with facility services. 4 out of 10 residents interviewed were unable to respond to LPA questions. 6 out 6 staff interviewed demonstrated understanding of position duties. All staff members present at the facility were observed to be fingerprint cleared on Guardian. LPA reviewed 10 resident files, all resident files were observed to be complete and up to date. LPA reviewed 8 staff files. 3 out of 8 staff files were observed not to have adequate yearly training hours for 2022. Facility disaster plan and plan of operation were observed to be complete and reviewed within a year's time.

Deficiency cited during today's visit. This report was reviewed with Administrator Griselda Galvan and a copy of the signed report was provided electronically due to printer error.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
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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Document Has Been Signed on 03/30/2023 10:08 AM - 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: AEGIS ASSISTED LIVING OF APTOS

FACILITY NUMBER: 445202706

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 8 staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2023
Plan of Correction
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Licensee has begun to implement electronic devices at facility to assist in providing necessary training, licnesee to assign specific hours to staff during their shift for the purpose of completing mandatory trainings. Licensee to submit written plan for provision of trainings to all necessary staff by POC due date.
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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
LIC809 (FAS) - (06/04)
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