286803028-6-8-2023-21-AS-CFES-CSLUJ9-20230608153710

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286803028
Report Date: 06/08/2023
Date Signed: 06/08/2023 03:37:16 PM

Document Has Been Signed on 06/08/2023 03:37 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	AEGIS ASSISTED LIVING OF NAPA		FACILITY NUMBER:	286803028
ADMINISTRATOR:	PAUL OSESO		FACILITY TYPE:	740
ADDRESS:	2100 REDWOOD ROAD		TELEPHONE:	(707) 251-1409
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	56	CENSUS: 50	DATE:	06/08/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Administrator, Paul Oseso		TIME COMPLETED:	03:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 1:40PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Paul Oseso, and Health Services Director, Lady Franz Tsang. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). Incident Report 1: CCL received an incident report on 05/18/2023. Review of the report stated that Resident 1 (R1), was found on the floor of their apartment. R1 was observed to be on their side with some bleeding on their elbow. Facility contacted Emergency Personnel and R1 was taken to the hospital to be evaluated. R1 had surgery and returned to the community. Facility made all appropriate notifications per regulation. LPA discussed R1 with Administrator and Health Services Director. LPA was informed that R1 was reinstated to Hospice after returning from the hospital, and has since passed away. Incident Report 2/Death Report: CCL received an incident report on 04/13/2023. Review of the report stated that Resident 2 (R2), was observed by their Primary Care Physician to have shortness of breath. Emergency Personnel was contacted and R2 was taken to the hospital to be evaluated. R2 was then admitted for further evaluation. Facility made all appropriate notifications per regulation. On 05/04/2023, LPA received a death report for R2 stating that they had passed away while at the hospital. LPA discussed R2 with Administrator and Health Services Director. Facility to request and submit a copy of R2's Death Certificate to CCL when it has been received. Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AEGIS ASSISTED LIVING OF NAPA	FACILITY NUMBER: 286803028
	VISIT DATE: 06/08/2023

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Continued from LIC809

Incident Report 3: CCL received an incident report on 04/20/2023. Review of the report stated that Resident 3 (R3), was found on the floor of their apartment. Facility contacted Emergency Personnel and R3 was taken to the hospital to be evaluated. R3 was diagnosed with a compression fracture. Facility made all appropriate notifications per regulation.
LPA discussed R3 with Administrator and Health Services Director. LPA was informed that R3 is in memory care and has since returned to the community. Their fracture has healed. R3 has been observed to be at baseline with no complaints of pain. Facility has scheduled for R3 to have physical therapy to help with their gait and balance.

Incident Report 4: CCL received an incident report on 04/24/2023. Review of the report stated that Resident 4 (R4), was found on the floor of their apartment. Facility contacted Emergency Personnel and R4 was taken to the hospital to be evaluated. R4 was diagnosed with a hip fracture. Facility made all appropriate notifications per regulation.
LPA discussed R4 with Administrator and Health Services Director. LPA was informed that R4 is in memory care and has since returned to the community. Their fracture has healed. R4 has been observed to be at baseline with no complaints of pain. Facility has scheduled for Home Health to provide wound care for R4 and has also scheduled physical therapy to help R4 with their gait and balance.

LPA conducted a walk through of the facility.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023

LIC809 (FAS) - (06/04)

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