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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803028
Report Date: 05/05/2021
Date Signed: 06/16/2021 10:25:09 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: 45DATE:
05/05/2021
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Paul Oseso/Rencelli FamularcarnoTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Angela Elliott, LPA Shannan Hansen, and LPA Erik Gonzalez-Campos, conducted a case management tele-visit with Paul Oseso, General Manager and Rencelli Famularcarno, Health Services Director. It is being conducted via tele-visit due to COVID - 19 precautions.

Community Care Licensing (CCL) received an incident report on 4/28/2021 for an incident occurring on 4/26/2021 for R1. Around 7:15 PM R1 was noted to be missing. R1's Wanderguard device was attached to their walker. Staff found R1 in an adjacent business' parking lot next door to the facility. A couple from the community was on the phone with the police at the time trying to find R1 help. R1 rode back to the facility at 7:30 PM, was assessed and determined to have no injuries. According to Paul, facility spoke with R1's doctor the day after the incident and there were no new orders. Paul indicated R1 does go out for dialysis but has a 1:1 during that time and this will continue when she goes out. Paul indicated because the Wanderguard was on R1's walker the alarm did not sound when they left the facility. LPA requested copies of facility's AWOL policy/protocol, Wanderguard policy/protocol and R1's care plan and LIC 602.

LPA requested documentation.

No citations issued for deficiencies at this time.

Signature on file.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
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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