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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803028
Report Date: 12/23/2021
Date Signed: 12/23/2021 03:59:05 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:
12/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Paul Oseso, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lopez conducted an unannounced case management inspection and met with Administrator, Paul Oseso. The purpose of the case management inspection was to obtain additional information regarding a self reported incident submitted to Community Care Licensing (CCL) on 12/6/21.

CCL received an incident report reporting an elopement. Resident #1 (R1) eloped from facility on 12/6/21. Staff immediately alerted staff to locate R1. Staff #1 (S1) drove down the street and found R1. R1 was brought back to facility. Facility contacted R1's responsible party and doctor. According to R1's Physician Report, R1 could not leave facility unattended. Facility conducted staff training and will monitor residents closely. LPA conducted interviews and received documentation during today's inspection.

As a result of this visit, the following deficiencies were observed, see LIC 809-D for deficiency cited. Civil Penalty applied for $250.00 for repeated violations within 12 month period for Regulation 1569.312(d)previously cited on 10/18/21.

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 conducted and appeal of rights provided. Report given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
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: 12/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2021
Section Cited

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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:
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Facility reported that R1 left facility unassisted. LPA gathered statements and documents from Administrator. 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.

**Civil Penalty assessed in the total amount of $250.00
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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: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2021
LIC809 (FAS) - (06/04)
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