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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803028
Report Date: 02/01/2024
Date Signed: 02/01/2024 02:55:41 PM


Document Has Been Signed on 02/01/2024 02:55 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
SANTA ROSA RO, 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: 46DATE:
02/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Health Services Director, Lady TsangTIME COMPLETED:
03:15 PM
NARRATIVE
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At approximately 11:40 AM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a Case Management Inspection on Incident Reports dated 01/14/2024 that were received by Community Care Licensing (CCL) on 01/22/2024. LPA met with General Manager (GM), Paul Oseso and Health Services Director (HSD), Lady Tsang.

Incident Report #1: Incident report states that Resident 1 (R1) had an order for Amoxicillin which was prescribed with instructions to give two capsules by mouth twice daily for five days beginning on 1/8. Medication Technician noticed that R1's Electronic Medication Administration Record (EMAR) no longer had an order for Amoxicillin but there were two capsules left in the bottle. The discrepancies in the EMAR and the bottle of medication appeared to be a result of missing a dose of medication, resulting in the facility sending CCL an incident report.

Per conversation with GM and HSD, the medication was prescribed as a 5 day dose, and MAR and EMAR reflect that it was given for 6 days, then it is noted on the EMAR that the last dose was given on 1/14, reaching a total of 7 days.
The medication was started on a paper MAR on 1/8/24 and then was continued onto the EMAR the evening of 1/10. MAR for the evening of 1/8 is marked with a circle. Per conversation, the circle can mean either a missed dose or an "excused miss" which can mean that the medication was given but not marked in the MAR. The medication technician on shift at the time of medication administration confirmed that the medication was passed. At this time, HSD, GM, and LPA concluded that the pharmacy inputted the incorrect instructions for the medication to be given for five days or accidentally included an additional two days of antibiotics.

Continued on LIC809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AEGIS ASSISTED LIVING OF NAPA
FACILITY NUMBER: 286803028
VISIT DATE: 02/01/2024
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Continued from LIC809\

Incident Report #2: Resident 2 (R2)s family member was visiting and informed the nurse that they found an unknown capsule on R2's coffee table. The capsule was found to be Tamiflu. It was unknown if the capsule was from the mornings medication pass or from a previous medication pass. The medication was given on the next scheduled medication pass. The resident did not have any adverse affects.
Per conversation with GM and HSD, R2 is cognitively aware. It is believed that the Medication Technician poured the medications and was confident that R2 would remember to take them. The Medication Technician then left R2 to take their meds without checking to make sure they were consumed.

LPA was provided with proof of medication training that has been conducted since the incidents. HSD and GM informed LPA of another upcoming medication training that is scheduled to be conducted on 02/06/2024. LPA is requesting staff attendance sign in sheet from scheduled training, as well as what topics are to be covered once the training is conducted.


**A Civil Penalty in the amount of $250.00 is being issued today due to a repeat violation of Regulation 87465(a)(4) within a 12-month period.**

Exit interview conducted. Copy of report, LIC809D, LIC421FC, LIC 811, Plan of Corrections, and Appeal Rights discussed and provided. Signature on forms confirms receipt of documents.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

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

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 02/01/2024 02:55 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
SANTA ROSA RO, 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: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. ...
(4)The licensee shall assist residents with self-administered medications as needed.
This requirement was not as evidenced by:
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ED and HSD have conducted medication training since the incidents. There is additional medication training to be conducted the week of 02/04/2024. LPA to be provided with proof of training as well as topics covered once conducted.
Deficiency cleared during visit.
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Based on record review, the licensee did not comply with the section cited above by not ensuring that the medications were given as prescribed.
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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: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
LIC809 (FAS) - (06/04)
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