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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803028
Report Date: 01/02/2024
Date Signed: 01/02/2024 01:12:02 PM


Document Has Been Signed on 01/02/2024 01:12 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 NAPAFACILITY NUMBER:
286803028
ADMINISTRATOR:PAUL OSESOFACILITY TYPE:
740
ADDRESS:2100 REDWOOD ROADTELEPHONE:
(707) 251-1409
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:56CENSUS: 47DATE:
01/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Paul OsesoTIME COMPLETED:
01:30 PM
NARRATIVE
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At approximately 9:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to several incident reports submitted to CCL ranging from October thru December 2023. LPA met with Executive Director Paul Oseso, reviewed records and interviewed staff.
Incident 1: On 10/05/2023, staff observed the same medication, Quetiapine 25mg, was entered into their computer system twice, thus R1 was being given the medication twice daily instead of only once a day from 09/26-10/04/2023. An investigation was conducted and found that one nurse had entered the medication into the system manually. The normal procedure is to not enter medications manually. The medication orders are sent to the pharmacy, which updates the system. Retraining was conducted for nurses on the process of confirming medications in their system. Retraining was conducted on how to handle and report medication incidents.
Incident 2: CCLD received a self reported SOC341, Report of Suspected Dependent Adult/Elder Abuse, on 10/11/2023. The report described an incident between two residents. Staff heard an altercation in the hallway and observed resident, R2, push resident, R3, to the ground and kick them. Staff separated residents and assessed them for injury. LPA reviewed resident care plans and found notes regarding resident behaviors and how staff should react. Training has been conducted on combative behaviors and how to report incidents. Staff followed their procedures and there were no injuries to resident.
Incident 3: On 12/27/2023, CCLD received an incident report regarding a resident that did not receive 2 of 6 daily applications of a medication from 12/11-23/2023. The medication order was put into the system to administer the medication during the night time hours, but the medication technician was not informed. Physician was notified and the dosing schedule was updated. Continued on LIC 809-C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2024
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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Document Has Been Signed on 01/02/2024 01:12 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/03/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed,
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Licensee conducted retraining for all Nurses and Medication Technicians on communications between nurses and staff and working with their computer system. POC cleared at time of visit.
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Licensee did not ensure resident received medication as prescribed by Physician. This poses an immediate Health and Safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2024
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: 01/02/2024
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Training has been conducted to address communication between nurses and medication technicians. ***This is a repeated violation of the same regulation section in a 12 month period. An immediate civil penalty is being issued in the amount of $250.***

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Paul Oseso and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2024
LIC809 (FAS) - (06/04)
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