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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601374
Report Date: 01/15/2025
Date Signed: 01/15/2025 12:04:30 PM

Document Has Been Signed on 01/15/2025 12:04 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
OAKLAND ASC, 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: 74DATE:
01/15/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Leslie Ibo, Health Services Director TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 1/15/2025 at 11:15 AM Licensing Program Analysts (LPAs) P.Manalo and L. Fontanilla conducted an unannounced Case Management visit regarding a self-reported incident. Health Services Director self-reported the incident on 01/13/2025. LPAs met with Health Services Director, Leslie Ibo, and explained the purpose of the visit.

LPAs obtained the following documents such as R1's Physician's Report, Emergency ID Face Sheet, Physician's Fax Report Notification, Discharge Summary from 12/20/2024, Internal Progress Notes, Care Plan, Individualized Service Assessment, Medication Administration Record (MAR), Appraisal Needs and Services Plan, and Staff Schedule.

LPAs requested a copy of the Death Certificate to be sent to CCLD on 02/15/2025.

No deficiencies cited during visit.

Exit interview was conducted with Health Services Director, and a copy of this report was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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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