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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003994
Report Date: 08/09/2023
Date Signed: 08/09/2023 03:48:03 PM

Document Has Been Signed on 08/09/2023 03:48 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: 66DATE:
08/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Tracy Lehner, Executive DirectorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home unannounced to conduct a case management inspection related to an incident report received by the Department.

On 8/5/23, an incident report was received regarding a memory care resident (R1). On 8/1/23, R1 was observed to have a cough, chills, and 103.1 degree F fever. R1 was tested for COVID-19 and the results came back negative. R1 was transported to the hospital and was discharged with a diagnosis of severe sepsis with acute organ failure and UTI. R1 returned to the facility with a new medication order of antibiotics.
During today's visit, LPA toured the memory care units and observed R1 in the activity room. LPA was informed that R1 does not have frequent UTIs. R1 has a Dementia diagnosis and experiences confusion. R1's fever was an indicator to the facility staff to have R1 sent to the hospital. Upon return from the hospital, R1 is back at baseline. R1 has a follow-up appointment scheduled with their primary care physician on 8/15/23. Facility staff provide R1 assistance with toileting needs and keep track of set times for assistance electronically. LPA obtained a copy of R1's service plan and electronic tracking of R1's toileting needs for the week of 8/1/23-8/9/23.

There are no deficiencies noted during today's inspection. Exit interview was conducted. Copy of report provided to Executive Director.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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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