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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803028
Report Date: 07/23/2024
Date Signed: 07/23/2024 03:26:52 PM


Document Has Been Signed on 07/23/2024 03:26 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: DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Myrene GaetaTIME COMPLETED:
03:40 PM
NARRATIVE
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At approximately 9:00AM, Licensing Program Analyst's (LPA's) Tony Loera and Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Care Director Myrene Gaeta and explained the purpose of the visit. Administrator Paul Oseso was not present, however Administrator certificate is current. LPA's toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and outdoor spaces. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. First Aid/CPR certification was current. Medications were also reviewed. LPA's followed up on two Unusual incident reports submitted by facility on 05/22/2024 and 06/20/2024. The incident reports were in regards to two different medication errors. This is the forth violation of the same code section within a 12 month period. ******* An immediate civil penalty is being issued in the amount of $1000.00.*******

The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required seven-day non-perishable and two day perishable supply of food. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguishers were fully charged. Facility has fire sprinklers throughout. Smoke detectors are all operational. Carbon Monoxide Detectors were present. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. Facility has been conducting drills every 3 months.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:


Evidence of control of property

LIC500- Personnel Report

Evidence of Liability Insurance


Continued on LIC809-C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AEGIS ASSISTED LIVING OF NAPA
FACILITY NUMBER: 286803028
VISIT DATE: 07/23/2024
NARRATIVE
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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 Myrene Gaeta 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: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/23/2024 03:26 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: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Facility did not provide medication as ordered on 05/18/2024 and 06/11/2024, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee conducted retraining for all medication staff on 06/18/2024. POC cleared at time of visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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