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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920145
Report Date: 01/16/2025
Date Signed: 01/16/2025 12:11:20 PM

Document Has Been Signed on 01/16/2025 12:11 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AEGIS SENIOR RESIDENCEFACILITY NUMBER:
345920145
ADMINISTRATOR/
DIRECTOR:		KONTSEMAL, ANASTASIIAFACILITY TYPE:
740
ADDRESS:3200 LA MADERA WAYTELEPHONE:
(888) 493-1459
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 4DATE:
01/16/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator- Anastasiia KontsemalTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 01/16/2025 Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to conduct a post- licensing inspection utilizing the care tool. LPA met with Administrator Anastasiia Kontsemal and explained the purpose of the visit. Today's census is four (4) with zero (0) residents on hospice services. Facility is licensed for capacity of six (6) and hospice waiver of four (4).

LPA and Administrator conducted a tour together to ensure the health and safety of residents in care. Areas toured included but not limited to resident bedrooms, bathroom, laundry room, garage and common areas.

During the tour, LPA observed three (3) residents in the common area watching television and one (1) resident to be in their room. LPA observed the kitchen to have sharps and medication locked and secured. LPA observed the facility to have two (2) days of perishable and seven (7) days of nonperishable foods. LPA observed fire extinguisher to be last serviced on 03/05/2024. LPA and Administrator completed the post-licensing inspection tool and facility was found to be in compliance.

LPA conducted a file review of residents files and personnel files.

As a result of today's inspection, no deficiencies cited.

Exit interview conducted and a copy of the report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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