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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003994
Report Date: 04/17/2023
Date Signed: 04/17/2023 03:58:06 PM

Document Has Been Signed on 04/17/2023 03:58 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:BILL PHELPSFACILITY TYPE:
740
ADDRESS:4050 WALNUT AVETELEPHONE:
(916) 972-1313
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 90CENSUS: 72DATE:
04/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Nurse, Marc WeissTIME COMPLETED:
04:15 PM
NARRATIVE
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On 4/17/23, Licensing Program Analyst (LPA), Kevin Mknelly, conducted a case management visit to follow-up on recent incident reports submitted to the regional office. LPA met with the nurse and explained the reason for the visit. LPA followed the Department's current Covid-19 precautions. LPA complied with facilities masking policy.

On 4/13/23, the regional office received an incident report that stated that on 04/03/2023 at 5:50 am. Noc Medication care manager (S1)gave the a new resident (R1) levothyroxine 75 mcg. The resident has an order for levothyroxine 50 mcg, R1 received an additional 25 mcg. Resident (R1) self-manages R1's own medication. R1 suffered no ill effects as a result and R1's physician recommended continue with regular scheduled doses. S1 received an in-service regarding the medication errors.

The facility also submitted a incident report regarding a medication issue which occurred on 4/8/23 regarding PRN medication for R2 administered by S1. R2 had an original prescription for half a 5 mg dose of pain medication. During a follow-up visit R1's physician gave a verbal order for a full tab of the same medication. On 4/14/23, R1's physician provided a written order for a full tablet.

However, records review found that the facility was in possession of a hospital discharge summary stating a half tab be given for R1's pain on 4/8/23. This summary was not signed by the physician.
Report continued...
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2023
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: 04/17/2023
NARRATIVE
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Records review and interviews conducted by LPA on 4/17/23 found that a medication error occurred on 4/3/23 involving R1 and S1, the error was not reported to CCL within 7 days of the occurrence of the 4/3/23 medication error and the facility did not have a signed physician's order for R2's medication given on 4/8/23.

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. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Stephanie Jameson . Copy of this report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2023 03:58 PM - It Cannot Be Edited


Created By: Kevin Mknelly On 04/17/2023 at 02:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2023
Section Cited
CCR
87465(a)(4)

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Incidental medical and dental care- (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by records and interviews that On 4/3/23, R1 received the wrong dose of medication. This posed an immediate risk to R1.
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Licensee will submit a written plan which addressed corrections to the process of medications taken from the med cart to be delivered to residents have identifying information on the med cup to insure delivery to the corrct resident by the POC date of 4/19/23.
Type B
05/01/2023
Section Cited
CCR
87465

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Incidental Medical and dental care- For every ... medication for which the licensee provides assistance there shall be a signed, dated written order from a physician. This requirement was not met based on records and interview that R2 did not have a signed order. This posed a potential risk.
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Licensee will submit signed physican's orders for all medication administered to R2 by the POC date of 5/1/23.
Type B
05/01/2023
Section Cited
CCR87211

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Reporting Requirements- (a) (1) A written report shall be submitted to the licensing agency...within seven days ... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met based on records review and interviews which found that a medication
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Licensee will provide documentation of staff training regarding reporting requirements, for those staff authorized to report, to ccl by the POC date of 5/1/23.
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error occured on 4/3/23 and was not reported to CCL until 4/13/23.
This posed a potential risk to resident
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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 Senty
LICENSING EVALUATOR NAME:Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023


LIC809 (FAS) - (06/04)
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