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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803028
Report Date: 06/15/2021
Date Signed: 06/16/2021 10:24:04 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: 47DATE:
06/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Paul OsesoTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Elliott met with Paul Oseso General Manager regarding incident on 6/4/2021 where R1 touched R2 inappropriately in the dining room. R2 was assessed after the incident. CCL did not receive an incident report, and did receive SOC 341. R1 and R2 have dementia. R1 has a history of inappropriate interactions with female residents. According to General Manager staff were instructed verbally to provide enhanced supervision and care plan is currently being amended to reflect enhanced supervision for R1. Facility will continue to monitor R1's interactions with other residents. LPA reviewed and requested copies of documentation.

No citations issued for deficiencies at this time.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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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