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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202706
Report Date: 09/11/2025
Date Signed: 09/11/2025 02:40:19 PM

Document Has Been Signed on 09/11/2025 02:40 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 ASSISTED LIVING OF APTOSFACILITY NUMBER:
445202706
ADMINISTRATOR/
DIRECTOR:		GALVAN, GRISELDAFACILITY TYPE:
740
ADDRESS:125 HEATHER TERRACETELEPHONE:
(831) 684-2700
CITY:APTOSSTATE: CAZIP CODE:
95003
CAPACITY: 100CENSUS: 82DATE:
09/11/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:General Manager J.P. RolletTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced case management visit to follow up on an incident where a resident eloped from the facility. LPA met with General Manager (GM) J.P. Rollet. LPA stated the purpose of the visit.

On 7/21/2025, the Department received an Incident Report (IR) dated July 18, 2025, stating Resident R1 had eloped from the facility at approximately 2:50PM. The IR states staff received a report from Staff S7 at approximately 2:50PM, where S7 reported ‘seeing a lady on the street that resembles one our residents.” The facility began a search for R1 and did not locate R1 in his/her room. Staff began a search in the area outside of the facility where S7 reportedly observed R1. R1 was located by facility staff at approximately 3:05PM, sitting on the side of the street across from the local fire station. R1 was being taken by paramedics for assessment due to falling and sustaining an injury to the head.

Based on Google Maps search, R1 was located approximately 0.7 miles away from the facility.

On 7/22/2025 and 9/11/2025, LPA Tarin interviewed Staff S1 to S6. 3 out of 6 staff did not observe R1 on the day of elopement. S1 and S4 stated he/she saw R1 in the facility between 2:45PM and 2:50PM. S6 states he/she observed R1 between 2:00PM and 2:30PM.

6 out of 6 staff stated R1 has a history of wandering behavior. 2 out of 6 staff stated R1 has eloped from the facility before 7/18/2025. S2 and S4 states R1 eloped in May 2024 but did not provide additional information.

NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 ASSISTED LIVING OF APTOS
FACILITY NUMBER: 445202706
VISIT DATE: 09/11/2025
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5 out of 6 staff stated R1 has a history of cutting his/her wanderguard bracelet off. S6 did not provide additional information.

LPA interviewed General Manager (GM). GM states the elopement occurred during a shift change, and "a lot of traffic was going through the front, which is the only way in and out of the community."

Based on review R1’s physician’s report dated 3/27/2024, lists R1’s diagnosis as neurocognitive disorder. R1’s mental condition is listed as confused/disoriented, has wandering behaviors, and R1 is not able to leave the facility unassisted. R1’s service plans dated 6/27/2024 states R1 has exiting seeking behavior, seeks out, loiters near or attempts to exit through doors and/or windows. R1’s Elopement Risk Assessment dated 7/13/2025 states R1 showing wandering and exit seeking behaviors, verbalize a desire to leave community/to go home, resident has a history of previous elopement. R1’s Elopement Risk Assessment also states “ Resident currently with wanderguard, However, resident have been finding ways to cut wanderguard bracelets…in the meantime will continue to replace wanderguard.

LPA reviewed previous incident submitted to the Department for R1 and found an elopement that was reported on 5/17/2024, where R1 eloped from the facility on 5/11/2024 when out on a walk. R1 was returned to the facility unharmed.

Based on review of R1’s hospital discharge paperwork dated 7/18/2025, R1 sustained a fractured left wrist and a closed head injury during the elopement.

NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2025 02:40 PM - It Cannot Be Edited


Created By: Marcella Tarin On 09/11/2025 at 02:12 PM
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 ASSISTED LIVING OF APTOS
FACILITY NUMBER: 445202706

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/12/2025
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights: (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met as evidenced by:
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ADM stated he will send a written plan of action on how the facility ensures residents with wandering behaviors and neurocognitive disorder will be kept safe. ADM stated he will also send a written letter of understanding regarding the regulation. ADM will submit POC to CCLD by POC due date 9/12/2025.
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Based on interview and record reviews, on 7/18/2025, R1 has neurocognitive disorder and left the facility unassisted and was found by facility staff outside of the community, sustaining injuries. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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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.
Jin Jackie
NAME OF LICENSING PROGRAM MANAGER:
Marcella Tarin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2025


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 ASSISTED LIVING OF APTOS
FACILITY NUMBER: 445202706
VISIT DATE: 09/11/2025
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An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, which resulted in R1 eloping from the facility.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.

This report was reviewed with General Manager J.P. Rollet and a copy of the report was provided. Appeal Rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Jin Jackie
NAME OF LICENSING PROGRAM ANALYST: Marcella Tarin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC809 (FAS) - (06/04)
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