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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003994
Report Date: 04/27/2023
Date Signed: 04/27/2023 02:15:27 PM


Document Has Been Signed on 04/27/2023 02:15 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: 69DATE:
04/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Donald StametsTIME COMPLETED:
02:15 PM
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On 4/27/23, Licensing Program Analyst (LPA) Kevin Mknelly, met with Donald Stamets to follow-up on incident report submitted to the regional office on 4/14/23, 4/22/23 and 4/25/23.
Upon entering the facility, analyst completed electronic screening and sign in. Analyst followed facility's policy and wore a surgical mask.

The report submitted on 4/14/23 was for a resident to resident incident of aggression of R1 toward R2. 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 4/22/23 was for a resident to resident incident of aggression of R1 toward R3. Records and statement found R1 to have dementia and to be a resident in the memory care section of the facility with R3. 1:1 caregiver for R1 noted in the 4/14/23 report was not begun until 4/26/23.
The report submitted on 4/25/23 was for a loss of money belonging to R4. The money was reportedly delivered to R4 by a family member on 4/20/23 for an upcoming outing. On 4/22/23 the money belonging to R4 was found to be missing.

LPA interviewed facility Director, Resident Care coordinator and R4. LPA Observed R1, R2 and R3 to having lunch with care givers present. LPA received the LIC 602 for R1 and the staff schedule for the period of reported incidents.
LPA requests the resident profile with resident emergency/ responsible party contacts for R1, R2, R3, R4.
As a result of today’s inspection, no deficiencies were found at this time.
Report was reviewed with the Director and copy provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
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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