347003994-4-14-2023-59-AS-KMKY-CQVRU7-20230414131927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003994
Report Date: 04/14/2023
Date Signed: 04/14/2023 01:21:19 PM

Document Has Been Signed on 04/14/2023 01:21 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 CARMICHAEL		FACILITY NUMBER:	347003994
ADMINISTRATOR:	BILL PHELPS		FACILITY TYPE:	740
ADDRESS:	4050 WALNUT AVE		TELEPHONE:	(916) 972-1313
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	90	CENSUS: 68	DATE:	04/14/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Ronald Stamets and Ana de la Cerda.		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An office meeting was held on April 14, 2023 at 11:00 PM on a Microsoft Teams Meeting video conferencing system review the Stipulation and Waiver and Order (Stipulation) adopted on March 28, 2023 and the next steps. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period and all current and future residents during probation will be notified. The following were in attendance: Regional Manager Alycia Berryman, Licensing Program Laura Munoz, , Licensing Program Manager, Licesning Program Manager- San Diego-Denise Powell, Licensing Program Analyst Kevin Mknelly and Aegis representatives Ronald Stamets, Ana de la Cerda. Alycia Berryman discussed the purpose and elements of this type of meeting. The Stipulation was reviewed with the Licensee who expressed their understanding. Items discussed at the meeting included, but not limited to: Stipulation contents · Findings · Revocation of License Aegis of Carmichael and Shadowridge- Stayed with Probation conditions · Revocation of Administrator Certification- William Phelps- stayed with probation · Exclusion of Michelle E Connor- stayed with probation · Revocation of Ventura License: discipline with statewide training · Appeals of $10,000 and $15,000 civil penalties denied · Future Application for a license, registration, certification or approval · Tolling of probationary period Report continued...

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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: 04/14/2023

NARRATIVE

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· Violation of Stipulation Term
· Completion of probation
· Violation of stipulation terms
· Completion of probation and future applications
· Department’s Authority
· Monitoring Fee
· Waiver of Hearing Rights
· Waiver of Appeal/Modification Rights
· Waiver of Claims
· Severable terms
· Public Record
· Signatures
· Counterparts
· Effective Date March 28, 2023
· No Oral modification

The Licensee/Respondent/Representative stated they would abide by the following:
ꞏ Abide by the contents/terms of the Stipulation (submit all documents timely)
ꞏ Operate the facility in strict compliance with the regulations and statutes governing the operation of a
residential care facility for the elderly.

CCLD will do the following:
ꞏ Increase monitoring

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. A virtual exit interview was conducted, and a copy of this report was provided via email for a signature. Donald Stamets agreed to return a signed copy to CCLD by COB 4/14/23.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

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