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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803028
Report Date: 06/22/2021
Date Signed: 06/22/2021 01:54:59 PM

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: 48DATE:
06/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Paul OsesoTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Elliott and LPA Erik Gonzalez-Campos, conducted a case management follow-up with Paul Oseso, General Manager.

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. Paul indicated because the Wanderguard was on R1's walker and the alarm did not sound when they left the facility. Documentation review confirms R1 was not able to leave facility unassisted.

There was another incident for R1 that occurred on 5/15/2021. R1 exited the building at 2:45 AM triggering the alarm. The alarm had gone off for a while and was not answered by S1 . R1 had Wanderguard on wrist triggering alarm. R1 was found by S2 at the entrance to the facility with two men who had re-directed R1 to come back into the building. R1 was assessed and determined to have no injuries. S1 was non-responsive during incident and was subsequently terminated. There has been an additional person at the front desk overnight, and R1 has a 1:1 up to 11:00 PM at night which began 5/21/2021. R1 has since moved to the Memory Care portion of the facility on 6/16/2021.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Administrator.

Immediate civil penalty for $500.00 was issued for Zero Tolerance , absence of supervision.

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

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 NAPA
FACILITY NUMBER: 286803028
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2021
Section Cited

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87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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Based on LPA record review, and interview, Licensee did not provide supervision to R1 on two occasions. The absence of supervision is an immediate risk to the Health, Safety and Personal Rights of residents in care. ***A Civil Penalty of $500.00 is being assessed.
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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) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2021
LIC809 (FAS) - (06/04)
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