<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803028
Report Date: 10/18/2021
Date Signed: 10/18/2021 03:55:36 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: 49DATE:
10/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Paul Oseso, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Lopez arrived unannounced for the purpose of following up on an incident involving a self reported incident submitted to Community Care Licensing (CCL). On 10/10/21 R1 went AWOL from the facility. LPA met with Administrator, Paul Oseso and Wellness Nurse, Florence Guiyab. LPA spoke with Administrator and Wellness Nurse and reviewed records. Physician's report indicates that the resident cannot be in the community without assistance from the staff. It was reported that R1 left facility. Med tech went to get R1. R1 was then walking back with staff. Facility reported to physician, responsible party and Community Care Licensing.


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 Paul Oseso and appeals right given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 10/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2021
Section Cited

1
2
3
4
5
6
7
1569.312(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. Based on review of incident report and interview with Administrator, this requirement has not been met as evidence by:
8
9
10
11
12
13
14
Facility reported that R1 left facility unassisted. LPA's gathered statements and documents from Administrator and Wellness Nurse. R1's Physician Report states that R1 cannot leave facility unattended. This is a potential risk to the health and safety of residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2