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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003994
Report Date: 07/19/2023
Date Signed: 07/19/2023 12:59:31 PM


Document Has Been Signed on 07/19/2023 12:59 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:AEGIS ASSISTED LIVING OF CARMICHAELFACILITY NUMBER:
347003994
ADMINISTRATOR:TRACY LEHNERFACILITY TYPE:
740
ADDRESS:4050 WALNUT AVETELEPHONE:
(916) 972-1313
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:90CENSUS: 69DATE:
07/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Tracy LehnerTIME COMPLETED:
01:00 PM
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On 7/19/23, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit findings and met with Executive Director (ED), Tracy Lehner .

The department has received theft/ loss reports regarding two (2) residents R1 and R2. In April 2023 and again in July 2023, R1 reported losses of $200 in April and July 2023 incidents. Also in July 2023, it was reported that R2 had $700 missing.

All incidents of theft/ loss noted in this report were reported as required. Local law enforcement have been notified and their findings are not available at this time.

The department collected records and conducted interviews of the three incidents. Visits to the facility to investigate the incidents occurred on 4/27/23, 7/6/23 and 7/11/23. It was found that R1 and R2 had their money in their rooms. Both R1 and R2 had lock boxes available to them and in two of the three incidents, money was taken from the lockboxes. Neither R1 nor R2 identified suspects for stealing their money.

On 7/11/23, LPA Mknelly conducted a facility visit and discussed the licensee’s internal investigation results. Interview statements and a video provided to the Director found circumstantial evidence of suspicious behavior of S1 over the previous months. Staff reported S1 to be in areas of the community to which she was not assigned. S1 was alleged to be in the vicinity of the facility when food or supplies were found missing in the facility. S1 had been observed to be in a resident room when that resident was away at the hospital. In these previous observations, S1 was not caught with stolen items.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AEGIS ASSISTED LIVING OF CARMICHAEL
FACILITY NUMBER: 347003994
VISIT DATE: 07/19/2023
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A video, provided to the Director, by a person who knew S1, of the inside of S1’s home showed what appeared to be trash bags from the same supplier as the facility’s and what appeared to be a vacuum clearer missing from the facility.
Based on the evidence to date, S1’s employment was terminated.
On 7/18/23, the ED contacted LPA Mknelly by phone to notify LPA that a third resident, R3, reported suspicious activity on their debit card. R3’s family reported that R3’s card had had the account’s email address and password changed. The ED recognized the information as being related to people known to S1.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care or personal rights. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed. Copy of 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: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/19/2023 12:59 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
07/26/2023
Section Cited
CCR
87468.2(a)(8)

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Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, … residents in privately operated residential care facilities … following personal rights: (8) To be free from …financial exploitation, ....
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Licensee submit proof of inservice regarding employees communicating issues or concerns regarding co-worker actions or inactions to management to address the concernd.

POC date is 7/26/23,
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This requirement was not met based on records and statements that S1 financially exploit three residents. This posed an immediate risk to resident’s personal rights.
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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: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023
LIC809 (FAS) - (06/04)
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