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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803028
Report Date: 01/08/2021
Date Signed: 03/24/2021 11:53:51 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:AEGIS ASSISTED LIVING OF NAPAFACILITY NUMBER:
286803028
ADMINISTRATOR:PAUL OSESOFACILITY TYPE:
740
ADDRESS:2100 REDWOOD ROADTELEPHONE:
(707) 251-1409
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:56CENSUS: 43DATE:
01/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Paul Oseso/Rencelli FamularcarnoTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Elliott conducted a case management tele-visit with Paul Oseso, General Manager and Rencelli Famularcarno, Health Services Director. It is being conducted via tele-visit due to COVID - 19 precautions.

The self reported incident occurred on 1/2/2021 and involved two residents. R2 was exposed to inappropriate behavior of R1. Notification to all required parties was completed by the facility.

New care plans have been developed for R1, R1 now has a motion sensor in their room to ensure that there is no reoccurrence of incident with any other resident. There have been no further incidents between R1 and R2. LPA requested documentation for R1 and R2.

No citations for deficiencies issued at this time.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2021
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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