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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601374
Report Date: 10/28/2024
Date Signed: 10/28/2024 03:31:00 PM

Document Has Been Signed on 10/28/2024 03:31 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:AEGIS ASSISTED LIVING OF FREMONTFACILITY NUMBER:
015601374
ADMINISTRATOR/
DIRECTOR:		TURNER, RYANFACILITY TYPE:
740
ADDRESS:3850 WALNUT AVENUETELEPHONE:
(510) 739-1515
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 110CENSUS: 68DATE:
10/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Leslie Ibo, Health and Wellness Director TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPAs) Manalo and Clancy-Czuleger arrived unannounced to conduct a case management visit in response to the Unusual Incident Report (UIR) submitted by the facility. LPA's met with Leslie Ibo, Health and Wellness Director and Ryan Turner Executive Director and explained the purpose of the visit.

Resident (R1) had a sudden death and was not on hospice. Health and Wellness Director (S1) stated that R1 was receiving morning adl’s with care staff when she started throwing up & loss consciousness. CPR was administered for about 45 minutes and tried to resuscitate. R1 had a history of colon cancer and colon diverticulitis, and had a diagnosis of dementia and hypertension. Police were called (badge #16133) and stated that the coroner does not need to visit the community.

No deficiencies cited during today's visit. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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