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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803028
Report Date: 05/25/2021
Date Signed: 05/26/2021 09:33:14 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: 45DATE:
05/25/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Paul Oseso/Rena FamularcanoTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Angela Elliott met with Paul Oseso General Manager and Rena Famularcano Resident Services Director regarding incident for R1 that occurred on 5/15/2021. R1 exited the building at 2:45 AM triggering the alarm. The alarm had gone off for a while and was not answered S1 . R1 had Wanderguard on wrist triggering alarm. R1 was found by S2 at the entrance to the facility with two men who had re-directed R1 to come back into the building. R1 was assesed and determined to have no injuries. S1 was non-responsive during incident and was subsequently terminated. There has been an additional person at the front desk overnight, and R1 has a 1:1 up to 11:00 PM at night which began 5/21/2021. LPA was given copies of Facilities AWOL policy and Wanderguard policy.

LPA also discussed mitigation plan which has not been approved. General Manager will re-submit to LPA by 5/28/2021.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
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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