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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003994
Report Date: 11/02/2022
Date Signed: 11/02/2022 01:13:16 PM


Document Has Been Signed on 11/02/2022 01:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:AEGIS ASSISTED LIVING OF CARMICHAELFACILITY NUMBER:
347003994
ADMINISTRATOR:BILL PHELPSFACILITY TYPE:
740
ADDRESS:4050 WALNUT AVETELEPHONE:
(916) 972-1313
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:90CENSUS: 69DATE:
11/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Bill Phelps, Acting AdministratorTIME COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood met with Acting Administrator, Bill Phelps, to conduct a case management visit. The purpose of today's visit is to follow-up on a Metro Fire Annual Inspection conducted at the facility by Sacramento Metropolitan Fire District on 10/12/22. A Metro Fire Annual Inspection report was generated and submitted to the Department on 10/27/2022. The Department reviewed the Annual Inspection report and determined that the facility had violations that are in both CA Fire Codes and Title 22. Today’s visit is to address the issues found in the Annual Inspection report that apply to Title 22.

Based on Metro Fire Annual Inspection report, the following Title 22 violations occurred:
- Doors to self close and latch should be repaired
- Fire extinguisher by room 203 should be serviced

Doors that self close and latch have been repaired as of today's inspection. Facility is currently waiting for fire extinguisher servicing company to service extinguisher by room 203. Facility contacted services for extinguisher on 10/28/2022 and company will come to service extinguisher at any time during the week.

As a result of today's inspection, per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with Acting Administrator. A copy of this report and appeal rights were provided. The Acting Administrator’s signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
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


Document Has Been Signed on 11/02/2022 01:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: AEGIS ASSISTED LIVING OF CARMICHAEL
FACILITY NUMBER: 347003994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2022
Section Cited

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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Based on interviews conducted, the facility did not esnure that certain fire safety devices were operable, which poses a potential health, safety, and personal rights risk to residents in care.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2