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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003994
Report Date: 01/16/2025
Date Signed: 01/17/2025 09:47:12 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/09/2025 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250109103619
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: 59DATE:
01/16/2025
UNANNOUNCEDTIME BEGAN:
12:25 AM
MET WITH:Tracy Lehner, Executive DirectorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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-Staff did not ensure resident's hygiene care needs were met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 1/16/25, and met with the Executive Director, Tracy Lehner, to deliver complaint investigation findings regarding the above listed allegation.
During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. According the R1's Individualized Assessment Form, dated 11/12/24, R1 should receive assistance with bathing 3 times per week. Upon review of the services received in December 2024, R1 received bathing assistance on 12/1/24, 12/4/24, 12/11/24, 12/18/24, 12/22/24, 12/25/24, which did not meet the 3 times per week agreement. Relevant party reported that R1 was observed to be wearing the same clothing for multiple days; however, R1's Individualized Assessment form indicated that R1 does not require assistance with dressing.
Based on records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.
Exit interview conducted. A copy of report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 59-AS-20250109103619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARMICHAEL
FACILITY NUMBER: 347003994
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).
This requirement is not met as evidenced by:
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Facility agrees to conduct an in-service training with staff ensuring they understand the importance of following the residents' individualized care plan. Facility agrees to submit a list of all participants with the date to LPA by the POC due dates 1/30/25.
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Based on documentation reviewed, the facility did not ensure resident (R1) was receiving assistance with bathing as agreed in the Individualized Assessment, which poses a potential health, safety, and personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/09/2025 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250109103619

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: 59DATE:
01/16/2025
UNANNOUNCEDTIME BEGAN:
12:25 AM
MET WITH:Tracy Lehner, Executive DirectorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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-Staff did not provide furniture accommodations to resident in care
-Staff did not provide housekeeping services to resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 1/16/25, and met with the Executive Director, Tracy Lehner, to deliver complaint investigation findings regarding the above listed allegations.
During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation.
Allegation: Staff did not provide furniture accommodations to resident in care
Relevant party reported that resident (R1) was informed prior to move in that their apartment would be fully furnished; however, were told later they need their own furniture. According the R1's Admission Agreement, signed on 11/26/24, the facility will provide basic furniture at an extra fee if residents are unable to provide their own furniture. Interview with resident (R3) indicated that they were provided furniture by the facility at an extra fee. Interview with resident (R2) indicated that they have their own furniture; however, acknowledged that they were aware of the Admission Agreement indicating that they can be provided furniture at an extra fee.
*************************************************Continued on LIC9099-C************************************************
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 59-AS-20250109103619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARMICHAEL
FACILITY NUMBER: 347003994
VISIT DATE: 01/16/2025
NARRATIVE
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Allegation: Staff did not provide housekeeping services to resident in care
Interviews with R2 and R3 indicated that they have never had issues with not receiving housekeeping services. R2 and R3 indicated that their garbage is changed daily. Interviews with staff (S1, S2, S3, and S4) indicated that the garbage is dumped daily in each residents' room.

Based on records reviewed and interviews conducted, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited.
Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/09/2025 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250109103619

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: 59DATE:
01/16/2025
UNANNOUNCEDTIME BEGAN:
12:25 AM
MET WITH:Tracy Lehner, Executive DirectorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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-Staff did not issue appropriate refund to resident or resident's authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 1/16/25, and met with the Executive Director, Tracy Lehner, to deliver complaint investigation findings regarding the above listed allegation.
During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation.

*** The findings for this complaint report were changed and a new 9099 now supersedes it. New findings can be found on subsequent 9099 dated February 20, 2025 ***




Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20250109103619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARMICHAEL
FACILITY NUMBER: 347003994
VISIT DATE: 01/16/2025
NARRATIVE
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*** The findings for this complaint report were changed and a new 9099 now supersedes it. New findings can be found on subsequent 9099 dated February 20, 2025 ***
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6