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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003994
Report Date: 05/10/2023
Date Signed: 05/10/2023 04:31:27 PM


Document Has Been Signed on 05/10/2023 04:31 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:DONALD STAMETSFACILITY TYPE:
740
ADDRESS:4050 WALNUT AVETELEPHONE:
(916) 972-1313
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:90CENSUS: 68DATE:
05/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kelly SmitleyTIME COMPLETED:
03:10 PM
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On 5/10/23, Licensing Program Analyst (LPA) Kevin Mknelly, met with Kelly Smitley to follow-up on an earlier case management visit on 4/27/23.
Upon entering the facility, analyst completed electronic screening and sign in. Analyst followed facility's policy and wore a surgical mask.

The incident reports discussed were submitted to the regional office on 4/14/23, 4/22/23 and 4/25/23.

The report submitted on 4/14/23 was for a resident to resident incident of aggression of R1 toward R2.
The report stated that on 4/13/23, (R1) “suddenly approached (R2) and slapped her on the face, grabbed her right shoulder and dragged her on her side.”
Records and statement found R1 to have dementia and to be a resident in the memory care section of the facility with R2. There was no prior history reported to LPA of aggressive behavior by R1 toward other residents. The report submitted on 4/14/23 by Aegis LVN, S1, stated that “suggested 1:1 caregiver for (R1) and DPOA agreed.” On 4/27/23, Administrator stated to LPA that 1:1 caregiver resources were being sought through an agency and that the 1:1 services began for R1 on 4/26/23.

The report submitted on 4/22/23, by S1, was for a resident to resident incident of aggression of R1 toward R3 occurred on 4/21/23. The report submitted by S1 for the 4/21/23 incident stated (R1) “ came to (R3) at her table and suddenly slapped and
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARMICHAEL
FACILITY NUMBER: 347003994
VISIT DATE: 05/10/2023
NARRATIVE
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punched her on the left side of her face.” Facility evaluation of residents involved found no injuries to residents. As the identified 1:1 caregiver identified as needed for R1 was not established between 4/13/23- 4/26/23 for their aggressive “sundowning” behaviors, and a second aggressive incident occurred during that time, the licensee failed to insure there is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified as defined in CCR 87705(c )(4).

Furthermore, LPA conducted additional reviews to staff working during the reported loss of money belonging to R4, sometime between the period of 4/20/23 for an upcoming outing. On 4/22/23 the money belonging to R4 was found to be missing. To date, the money has not been recovered and no witness to a theft have been found. However, on 4/21/23 and 4/22/23, staffing agency contracted staff, S2, was present and assigned to assist R4 and other residents.
A criminal records clearance review of staff present at the facility found S2 to not have a criminal background clearance on file with the Department of Social Service. The agency that employed S2 and who contracted with the licensee is a staffing agency and not a home care organization. Nor were records found that S2 is a registered home care aid.
Residency agreements state- person who provides client assistance in dressing, grooming, bathing, or personal hygiene. care, toileting, transferring and similar care must be provided by our staff. The licensee failed to ensure that any person who provides client assistance in dressing, grooming, bathing, or personal hygiene had undergone criminal record clearance as identified in Health and Safety Code 1569.17(b)(1)(C). S2 had worked at this facility greater that 5 days.

Lastly, documents presented to LPA by the Administrator on 4/27/23 as well as a phone conversation with a representative of the staffing agency for whom S2 was employed found that only verification of mandated reporter training was on file for S2. The representative from the staffing agency confirmed that they are not aware of RCFE staff training
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
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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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: AEGIS ASSISTED LIVING OF CARMICHAEL
FACILITY NUMBER: 347003994
VISIT DATE: 05/10/2023
NARRATIVE
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Citations and civil penalties are therefore issued.

Report was reviewed with the Director and copy of the report and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/10/2023 04:31 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2023
Section Cited

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Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: 4) There is an adequate number of direct care staff to support each resident’s … safety and health care needs as
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The licensee has addressed the immediate risk at this time.
Licensee will will submit written procedures to be followed when a resident is identified as a risk to self or others that respod to that identified care need in a timely manner, by the POC date of 5/15/23.
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identified in his/her current appraisal. This requirement was not met based on statements and interviews regarding R1, 4/13/23 to 4/26/23. This posed an immediate risk to other residents.
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Type A
05/15/2023
Section Cited

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Fingerprints and criminal records of individuals in contact with clients (b) In addition to the applicant... apply to ... following persons: (1) (C) Any person who provides client assistance in dressing, grooming, bathing, or personal hygiene… This requirement was not met
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S2 was immediate removed from further presence at the facility and further contracts with the staffing agency was discontinued.

Licensee will submit a policy for screening and onboarding of "agency"
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based on records and statements that found S2 to have neither proof of certification nor criminal record clearance. This posed an immediate risk to residents in care. Civil penalties are issued.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 05/10/2023 04:31 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2023
Section Cited

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Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living (ADL) shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met based on
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Licensee will submit a policy for screening and onboarding of "agency" staff to insure required training is completed current for staff working at the facility before allowed to work unsupervised with residents.
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records review and interviews that found S2, as a staffing agency staff who provided ADL assistance to residents in care, did not have proof of required training either through the facility nor the staffing agency. This posed a potential risk to residents.
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Document to be submitted by the POC date of 5/24/23.

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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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