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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003994
Report Date: 01/23/2024
Date Signed: 01/23/2024 04:06:07 PM


Document Has Been Signed on 01/23/2024 04:06 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:
01/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Tracy Lehner, AdministratorTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with General Manager (GM), Tracy Lehner, to conduct a case management visit. The purpose of today's visit is to follow up on an Unusual Incident/Injury Report (SIR) that was received by the Department on 1/18/2024.

On 1/14/2024, at approximately 3:40pm, Life's Neighborhood courtyard gate sounded and alerted facility staff. Staff responded and conducted a full sweep of the community and identified resident (R1) was missing from the community. Staff called 911 and alerted R1's family. R1's family informed staff of R1's Airtag and began tracking R1 via GPS. R1 was located at Bel Air on Cypress by police. R1 was found at approximately 5:20pm and brought back to the community.

GM stated that R1 was located approximately 2 blocks away from the facility. GM stated that an elopement drill was completed with facility staff and R1 will be moving to Life’s Neighborhood. LPA observed Training Attendance Record for Elopement Protocol Training.

LPA observed R1's Physician's Report for RCFE LIC 602A dated 8/23/2023, which states that R1 is not at risk if allowed to leave the community unsupervised due to dementia or cognitive decline. LPA observed that R1 does not have a diagnosis of dementia according to their LIC 602A dated 8/23/2023.

Exit interview was conducted with GM. A copy of this report was provided. The GM’s signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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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