Aegis Assisted Living of Carmichael

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. Administrator was present to assist. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is very clean and well maintained. LPA reviewed 6 resident files. Files are complete and well organized. LPA reviewed 5 staff files. Files are complete. LPA requested the following documents to update the facility file: LIC 308- designee (if applicable), Liability Ins. cert. and Current LIC 500. No deficiencies are being cited as a result of todays inspection. Exit interview conducted with licensee and copy of report left at the facility.the state’s words, verbatim · CDSS document, May 13, 2026

Type of visit: Case Management - Incident

On 4/22/26, LPA Kevin Mknelly conducted a case management visit and met with Administrator. The purpose of the visit is to review a recent incident involving R1's elopement on 4/10/26. On 4/10/26, a med tech discovered R1 to not be in their room at approximately 8 PM. A search of the Assisted Living area where R1 resides found R1 to not be present. R1 returned on their own and unharmed at approximately 8:25 PM. Review of medical records found that R1 has a diagnosis of mild cognitive impairment and to use a walker as an ambulation assisted device. Interview found that experience recent episode of confusion and exit seeking and that resident had agreed to use of a wander guard. On the day of the elopement, R1 did not demonstrate active exit seeking before going to their apartment. LPA reviewed the security measures used at the community for entering /exiting the building. The front door has an alarm that is to be activated after 7 PM. The community also used the "Augi " monitoring system in resident rooms (if agreed to). In the 4/10/26 incident, staff were not alerted by the front door alarm nor the wander guard alert, allowing R1 to leave the facility unassisted until a staff check for their absence. R1's physician report on file has the recommendation that R1 not leave unassisted. R1's recent change of condition warranted a significant change for which a reappraisal was to be conducted. While a wander guard was in place, all additional measures of monitoring and procedures such as facility door alarm function and that staff would be alerted to the alarm were not verified. As a result of this inquiry, a deficiency was found. Report was reviewed with copy and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 22, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(g) · Plan of correction due date: May 6, 2026

Reappraisals- (g) The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident. This requirement was not met based on records and interviews. This posed a potential risk to R1.the state’s words, verbatim · CDSS document, Apr 22, 2026

Plan of correction: Licensee will submit a statement of corrective actions put in place as a result of this incident, including but not limitted to alarm systems function and adequate auditory alerts to staff and elopement procedures for the time until police are notified for a search. The POC is due 5/6/26.

Allegation investigated: Staff do not ensure the residents have comfortable accommodation’s.

On 4/2/26, Licensing Program Analyst (LPA) Kevin Mknelly LPA Mknelly arrived and met with Administrator to inform them of the complaint investigation and to then deliver investigation findings. LPA conducted interviews. LPA finds that facility met Tittle 22 requirements. LPA interviewed the administrator and met R1 breifly. It was alleged that a resident's loud speaking within the community imposes on the comfortable living accomodations of other residents. LPA's interviews and observations found that the resident who is at times speaks very loudly does so secondary to medical conditions. The loud resident is appropriate to the level of care provided in assisted living and is not violating house rules or the personal rights of others. LPA and Administrator discussed possibilities of a guest speaker for educating residents on the challenges and opportunites of living with others of differing disability. Administrator will also work with Unfounded family and healthcare providers for possibilities of additional voice volume corrections for the resident who speaks loudly. As Title 22 regulations address personal accommodations in terms of safety, environmental comfort and privacy, personal accommodations requirements are not applicable to this situation. Additionally, resident personal rights protect person's with disability from discrimination and exclusion when the disability presentation poses no harm to others. Therefore this complaint is unfounded. This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview conducted and report provided by email.the state’s words, verbatim · CDSS document, Apr 2, 2026 · control 59-AS-20260327081226

Type of visit: Case Management - Other

On 12/2/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit met with the Executive Director . The department has received three incident reports, between 1/30/26 and 2/16/25, regarding R1 and and two other residents (R2 and R3). LPA and Director, health service director discussed behavioral expressions and the communities methods for addressing R1's behaviors. Also discussed the supervision and monitoring of R1's movements and status in the community to ensure R1's safety. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Feb 23, 2026

Type of visit: Case Management - Other

On 12/2/25, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with the Executive Director . On 11/21/25 , the department received an incident report that described an interaction between R1 and R2 in which R1 sustained a small skin tear. LPA and director reviewed the incident and measures taken. It was found that R1 had inadvertently touched R2's walker as they past one another. When R2 pulled their walker back, R1 was scratched by the walker. No prior or further incidents have occurred between the two. LPA and Director discussed behavioral expressions and the communities methods for addressing behaviors. LPA received a copy of licensee's Plan of Operations. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Dec 2, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced and met with the General Manager, Paul Oseso, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed four (4) bedrooms in assisted living, three (3) bedrooms in memory care, and three (3) common area bathrooms. LPA observed apartments to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 110.8 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives, cleaning products and other toxins to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguishers are maintained and ready for emergency use. LPA reviewed three (3) assisted living resident files and two (2) memory care resident files. LPA also reviewed five (5) staff files. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jun 17, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 3/26/2025 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 3/28/2023-3/28/2025. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review upon request. LPA met with the Care Director, Kelly Smitley. During today's visit, LPA reviewed the following stipulations of the order: 1. Staff shall have criminal record clearance -LPA checked criminal record clearance for all staff 2. Staff have current CPR training certification -LPA observed current CPR certifications for staff 3. All medications and toxins shall be locked away and inaccessible to residents -LPA observed all medications and toxins to be locked away 4. Facility shall be clean, safe, and sanitary -LPA toured facility which was clean, safe, and sanitary LPA observed facility to be in compliance and residents receiving care. No deficiencies are being cited. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Mar 26, 2025

Allegation investigated: -Staff did not issue appropriate refund to resident or resident's authorized representative

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, February 20, 2025, and met with the Administrator, Tracy Lehner, and Business Office Manager, Melissa Bell, to amend and deliver complaint investigation findings from a visit conducted on January 16, 2025. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. Resident (R1) moved out of the care home after residing at the home for 54 days. According to facility's Community Fee Refund Calculation form, R1 is due 60% of their Community Pre-Admission Fee in the amount of $3300. Originally, the facility applied the 60% fee towards R1's remaining rent balance due. **********************************************Continued on LIC9099-C*************************************************** Substantiated However, the Community Pre-Admission Fee is a separate charge than a resident's rent. Facility agrees to refund R1 the 60% Community Pre-Admission Fee, and moving forward will obtain written consent from a resident or responsible party if applying the Community Pre-Admission Fee towards any other remaining balance owed to the facility. Based on records reviewed and interviews conducted, 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.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 59-AS-20250109103619

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(5)(E)(2)(b) · Plan of correction due date: Mar 6, 2025

87507 Admission Agreements (g) Admission agreements shall specify the following: (5) Refund conditions. (E) Preadmission fees shall be refunded according to the following conditions: 2. Unless Section 87507(g)(5)(E)1. applies, paid preadmission fees that are greater than five hundred dollars ($500) shall be refunded to an applicant, resident, or the applicant/resident’s representative in the following manner: b. A refund of at least 60 percent of the preadmission fee in excess of $500 shall be provided if the resident leaves the facility for any reason during the second month of residency. This requirement is not met as evidenced by: Based on documentation reviewed and interviews conducted, the facility did not refund resident (R1) 60% of their Community Pre-Admission Fee upon moving out of the facility, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 20, 2025

Plan of correction: Facility agrees to refund R1 60% of the Community Pre-Admission Fee totaling $3,300. Facility will submit a statement of understanding to LPA by the POC due date of 3/6/2025.

Allegation investigated: -Staff did not ensure resident's hygiene care needs were met

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 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. *** 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 ***the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 59-AS-20250109103619

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 30, 2025

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: 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.the state’s words, verbatim · CDSS document, Jan 16, 2025

Plan of correction: 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.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 1/16/25 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 3/28/2023-3/28/2025. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review upon request. LPA met with the Executive Director, Tracy Lehner. During today's visit, LPA reviewed the following stipulations of the order: 1. Staff shall have criminal record clearance -LPA checked criminal record clearance for all staff 2. Staff have current CPR training certification -LPA observed current CPR certifications for staff 3. All medications and toxins shall be locked away and inaccessible to residents -LPA observed all medications and toxins to be locked away 4. Facility shall be clean, safe, and sanitary -LPA toured facility which was clean, safe, and sanitary LPA observed facility to be in compliance and residents receiving care. No deficiencies are being cited. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jan 16, 2025

Allegation investigated: -Facility did not issue refund.

Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 9/5/24, and met with the Executive Director, Tracy Lehner, to deliver complaint investigation findings regarding the above stated allegation. During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. Upon review of the facility's Payer Detail Ledger, dated 12/26/23-6/30/24, LPA observed that the facility does not owe the resident (R1) a refund. LPA obtained a copy of R1's admission agreement. LPA observed that the facility is complying with the terms and conditions set forth in the admission agreement. Based on documentation reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Sep 5, 2024 · control 59-AS-20240618163109

Allegation investigated: Staff did not prevent resident from eloping from the facility.

LPA Parks arrived on Tuesday July 23, 2024 to open a complaint investigation regarding the above allegation. LPA discussed the allegation with Administrator Tracy and Health Services Director Tayjahana. Through interviews, LPA learned that R1 moved out of the facility on 7/10/2024, into the care of their daughter. At the time of the incident where R1 was found, they were not a resident at this facility. During R1's stay at the facility, there were no instances of R1 eloping. LPA obtained a 30 day notice for R1 and documenation showing that R1 was discharged from care on 7/10/2024. Based on the evidence provided, the preponderance of evidence standards was not met, therefore, the above allegation is found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of this report was left at the facility. Exit interview conducted. A copy of this report was emailed to the administrator. Unfoundedthe state’s words, verbatim · CDSS document, Jul 23, 2024 · control 59-AS-20240720224011

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Parks arrived on Monday May 13, 2024 to conduct the unannounced annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (7) and staff (7) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training. Facility is complaint with fire drills. LPA and Maintenance Director toured the facility together to ensure the health and safety of residents in care. The areas toured included memory care apartments, memory care common areas, memory care courtyard, assisted living apartments, assisted living courtyard, lobby, kitchen, and dining room. LPA observed the facility's emergency food, water storage and PPE. LPA observed all required postings. LPA observed emergency evacuation chairs in each stairwell. First aid kit was fully stocked. In the areas toured, there were no health or safety violations observed. LPA obtained a copy of the facility's current liability insurance, LIC500, and LIC610E. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, May 13, 2024

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 3/26/24 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 3/28/2023-3/28/2025. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review upon request. LPA met with the Executive Director, Tracy Lehner. During today's visit, LPA reviewed the following stipulations of the order: 1. Staff shall have criminal record clearance -LPA checked criminal record clearance for all staff 2. Staff have current CPR training certification -LPA observed current CPR certifications for staff 3. All medications and toxins shall be locked away and inaccessible to residents -LPA observed all medications and toxins to be locked away 4. Facility shall be clean, safe, and sanitary -LPA toured facility which was clean, safe, and sanitary 5. Facility shall conduct monthly quality assurance audits for 1 year -LPA observed monthly quality assurance audit reports LPA observed facility to be in compliance and residents receiving care. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Mar 26, 2024

Type of visit: Case Management - Incident

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.the state’s words, verbatim · CDSS document, Jan 23, 2024