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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003994
Report Date: 03/23/2023
Date Signed: 03/23/2023 03:01:02 PM


Document Has Been Signed on 03/23/2023 03:01 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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:
03/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Donald StametTIME COMPLETED:
03:15 PM
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On 3/23/23, Licensing Program Analyst (LPA), Kevin Mknelly, conducted a case management visit for and incident reported. LPA met with Interim Director and explained the reason for the visit. LPA followed the Department's current Covid-19 precautions and wore a surgical mask while present .
Staff were wearing masks.

LPA spoke with the Director, Health Services Director and Medication Technician.

R1 presented with illness on the morning of 3/15/23. Medical care was called in a timely fashion. R1 was hospitalized for days and returned to the community at baseline.

As a result of todays inspection there are no deficiencies cited at this time.

Report reviewed with Donald Stamet. Copy of the report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
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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