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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003994
Report Date: 08/23/2023
Date Signed: 08/23/2023 03:46:18 PM


Document Has Been Signed on 08/23/2023 03:46 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: 67DATE:
08/23/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Tracy Lehner, Executive DirectorTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Angela Hood and Jaynae Boyles arrived at the facility unannounced on 8/23/2023 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 3/28/2023-3/28/2025. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review upon request. LPAs met with the Executive Director, Tracy Lehner.

During today's visit, LPAs reviewed the following stipulations of the order:

1. Staff shall have criminal record clearance
-LPAs checked criminal record clearance for all staff

2. Staff have current CPR training certification
-LPAs observed current CPR certifications for staff

3. All medications and toxins shall be locked away and inaccessible to residents
-LPAs observed all medications and toxins to be locked away

4. Facility shall be clean, safe, and sanitary
-LPAs toured facility which was clean, safe, and sanitary

5. Facility shall conduct monthly quality assurance audits for 1 year
-LPAs observed monthly quality assurance audit reports

LPAs observed facility to be in compliance and residents receiving care. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
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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