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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003994
Report Date: 06/13/2023
Date Signed: 06/13/2023 03:05:30 PM

Document Has Been Signed on 06/13/2023 03:05 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:DONALD STAMETSFACILITY TYPE:
740
ADDRESS:4050 WALNUT AVETELEPHONE:
(916) 972-1313
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 90CENSUS: 67DATE:
06/13/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Donald StametsTIME COMPLETED:
09:45 AM
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On 6/13/22, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit as well as an annual inspection (reported separately) and met with the Administrator .

The purpose of the visit was to review compliance with conditions of the Stipulation. All conditions are met.

The residence is clean, safe and sanitary.


As a result of today’s inspection, no deficiencies were noted.


Report reviewed. Copy of report provided
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2023
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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