Aegis Assisted Living of Napa

Type of visit: Case Management - Incident

On 04/15/2026, at approximately 1:40 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management- incident inspection and met with Paul Oseso, Administrator. LPA is conducting a case management visit to obtain more information regarding a series of incident reports (IRs) and an SOC341 received by the Department. LPA obtained documents, made observations, and conducted interviews. On 05/14/2026, the Department received a self-reported IR regarding an elopement on 05/13/2026 of Resident 1 (R1) who per their physician's report dated 01/17/2026 is unable to leave the facility unassisted, (see LIC809D). On 04/20/2026, the Department received a self-reported IR regarding a medication error which occurred on 04/12/2026 for Resident 2 (R2) whose medication was observed by staff missing two tablets resulting in R2 missing two prescribed doses as reflected in R2's medication administration record (MAR) for 04/2026, (see LIC809D). On 04/29/2026, the Department received a self-reported IR regarding an altercation involving memory care Resident 3 (R3) and Resident 4 (R4). LPA reviewed records, obtained copies of documents and conducted an interview with Staff 1 (S1). Continued on LIC809C... Continued from LIC809... All required parties were notified in the required time frames, R3's medications have been adjusted, supervision and redirection have been increased, and facility continues to monitor the situation. On 05/19/2026, the Department received a self-reported IR regarding Resident 5 (R5) and on 05/22/2026, the Department received a self-reported IR regarding Resident 6 (R6). Each experienced a fall in their room which was captured by the facility's Augi system. LPA observed and obtained more information on the monitoring system mentioned in the reports and will return to the regional office (RO) to discuss further with Licensing Program Manager (LPM). The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and appeal of rights provided. Signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jun 1, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jun 1, 2026

87411(a) Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on record review, self-report, and interview conducted with S1, R1 eloped from the community without staff knowledge and staff did not prevent R1 from wandering away from the facility which poses an immediate Health, Safety and/or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 1, 2026

Plan of correction: Licensee to submit self-certification that an elopement prevention training has been schduled and/or completed by POC due date of 06/01/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(4) · Plan of correction due date: Jun 1, 2026

Incidental Medical and Dental Care 87465(a)(4)The licensee shall assist residents with self-administered medications as needed.. This requirement is not met as evidenced by: Based on record review, self-report, and interview conducted with S1, R2 missed two doese of their prescribed medication, which poses an immediate Health, Safety and/or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 1, 2026

Plan of correction: Licensee to submit self-certification that a medication error prevention training has been schduled and/or completed by POC due date of 06/01/2026.

Allegation investigated: Personal Rights. Staff does not ensure resident is hydrated. Staff do not keep the facility clean and sanitary.

On 04/20/2026, at approximately 10:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conclude investigation and deliver findings regarding LIC802 - Complaint Report #21-AS-20260112103418, which was received by Community Care Licensing (CCL) on 01/12/2026. Reporting Party (RP) alleges a personal rights violation, staff does not ensure resident is hydrated, and staff do not keep the facility clean and sanitary. LPA met with Paul Oseso, Administrator. During 01/14/2026 facility visit, LPA completed a walk through of the facility with Administrator, made observations, obtained documents, and conducted interviews. LPA found the facility to be clean and sanitary and witnessed housekeeping cleaning resident rooms. Based on an interview conducted with Administrator, residents' rooms are cleaned weekly. At minimum, this includes: vacuuming, mopping, dusting, beds are stripped and sheets and towels are washed. Kitchen's and bathrooms are cleaned weekly as well. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Additionally, residents' trash is checked daily and is dumped if needed. Residents' personal laundry is washed by the care staff once per week. If anything needs to be addressed and cleaned, it is dealt with immediately. The other common areas and public restrooms are cleaned daily. Interviews conducted with Resident 1 (1), Staff 1 (S1), and Staff 2 (S2) on 01/14/2026, interviews conducted with Staff 3 (S3), Staff 4 (S4) and Witness 1 (W1) on 02/24/2026, and interviews conducted with Witness 2 (W2) on 03/30/2026, Witness 3 (W3) on 04/15/2026, and Witness 4 (W4) and Witness 5 (5) on 04/15/2026 revealed conflicting information as to whether R1 was forced to shower or not. While photos dated 01/07/2026 were provided to LPA and show broken finger nails, there is no way to confirm when or how they occurred. Hospital records dated 01/11/2026 reveal that ER personnel were encouraging food and hydration but R1 refused. Additionally, while a third party Hospice agency record dated 01/26/2026 indicate that R1 was malnourished, R1 moved out of the facility on 01/16/2026 and the above mentioned interviews conducted with S1, S3, and S4 revealed that residents are offered water and fluids with every meal, and the evening shift caregivers ensure the residents each have fresh water available in their rooms. LPA received conflicting information regarding each of the above allegations. Based on interviews conducted, observations made, and records obtained, the allegations of a personal rights violation, staff does not ensure resident is hydrated, and staff do not keep the facility clean and sanitary are UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt of document(s).the state’s words, verbatim · CDSS document, Apr 20, 2026 · control 21-AS-20260112103418

Allegation investigated: Staff do not follow resident's care plan.

On 04/20/2026, at approximately 10:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conclude investigation and deliver findings regarding LIC802 - Complaint Report #21-AS-20260112103418, which was received by Community Care Licensing (CCL) on 01/12/2026. Reporting Party (RP) alleges that staff do not follow resident's care plan. LPA met with Paul Oseso, Administrator. During facility visit on 01/14/2026, LPA obtained documents and conducted interviews. Per the care plan for Resident 1 (R1) dated 12/26/2025, R1 was independent with bathing and did not have shower assistance included in their care plan. Per interviews conducted with Staff 1 (S1) and Staff 2 (S2) during this visit, and further interviews conducted on 02/24/2026 with Staff 3 (S3) and Staff 4 (S4), it was revealed that staff did assist R1 with bathing. Facility was able to provide email correspondence with R1's responsible party regarding bathing assistance and the responsible party indicated they would bring R1's shower chair to the facility. Continued on LIC9099C... Substantiated Continued from LIC9099... However, there was no official reappraisal conducted for R1 which included bathing assistance. Based on documents obtained and interviews conducted, the allegation that staff do not follow resident's care plan is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided to Administrator.the state’s words, verbatim · CDSS document, Apr 20, 2026 · control 21-AS-20260112103418

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(b) · Plan of correction due date: May 22, 2026

Reappraisals 87463(b)The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition.... This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not ensure that R1's appraisal needs and services plan was followed or that a reappraisal was completed prior to implementing new services. This poses a potential Health, Safety and/or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 20, 2026

Plan of correction: Licensee to conduct training with staff regarding compliance with residents' appraisal needs and services plan and completing reappraisals when indicated and submit proof to CCLD by POC due date of 05/22/2026.

Type of visit: Case Management - Incident

On 04/15/2026, at approximately 3:30 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management- incident inspection and met with Paul Oseso, Administrator. LPA is conducting a case management visit to obtain more information regarding a series of SOC341s and incident reports received by the Department involving altercations involving memory care Resident 1 (R1) and Resident 2 (R2) on 03/13/2026 and another on 03/17/2026; R1 and Resident 3 (R3) on 04/09/2026; Resident 4 (R4) and Resident 5 (R5) on 03/12/2026; and R1 and R4 on 04/13/2026. LPA reviewed records and obtained copies of documents regarding R1 and R4. LPA conducted an interview with Staff 1 (S1). All required parties were notified in the required time frames. No deficiencies were cited during todays visit. Exit interview was conducted with Paul Oseso, Administrator, whose signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, Apr 15, 2026

Type of visit: Required - 1 Year

At approximately 9:15 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Paul Oseso, Administrator. Facility is an Residential Care Faciity for the Elderly (RCFE) with 48 residents in care, 14 of whom reside in the memory care unit. The community has a Hospice waiver for 10 and is approved for 8 bedridden residents. At approximately 10:30 AM, LPA initiated a tour of the community with Administrator and observed the following: Facility is a two story building with evacuation chairs observed at the top of each stairwell. Facility was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of paper products available to clients. Closets containing cleaning supplies and other items that could pose a risk were locked. The community has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There are covered seating areas and outdoor space for activities. LPA observed an activity schedule, residents engaged in activities, and computers with internet available for resident use. The community's fire extinguishers were observed charged and were last serviced 02/2025. Sprinklers and Smoke and Carbon Monoxide detectors were last inspected by the Napa Fire Department 10/2024. Facility conducts monthly emergency/disaster drills with the last one conducted 07/2025. LPA observed facility's infection control plan and emergency disaster plan which was last updated 07/2022. LPA observed a supply of PPE, emergency supplies, flashlights and a first aid kits throughout the community. continued on LIC809C... Continued from LIC809... Facility has a backup generator for emergency preparedness. At approximately 11:15 AM, LPA reviewed seven (7) resident records and seven (7) staff records. Seven (7) out of seven (7) resident's records have all the required paperwork, including current medical assessments and care plans. 7 out of 7 staff records have current required training and current First Aid/CPR certification. Medication and medication records were reviewed and found managed and stored in compliance with regulation. Facility works with residents and their families to coordinate medical and dental visits as well as transportation to and from appointments. Facility does not manage P&I cash resources. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: -LIC610 - Emergency Disaster Plan -A copy of facility's liability insurance No Deficiencies are cited during inspection. Exit interview conducted with Administrator whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 7, 2025

Type of visit: Case Management - Incident

On 07/15/2025, at approximately 3:30 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management- incident inspection and met with Lady Franz Tsang, Health Services Director. LPA is conducting a case management visit to obtain more information regarding a death report received by the Department on 07/14/2025, involving the death of Resident 1 (R1) on 07/10/2025. LPA reviewed R1's records and obtained copies of documents including a personnel roster/report. No deficiencies were cited during todays visit. Exit interview was conducted with Health Services Director, whose signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, Jul 15, 2025

Type of visit: Required - 1 Year

At approximately 9:00AM, Licensing Program Analyst's (LPA's) Tony Loera and Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Care Director Myrene Gaeta and explained the purpose of the visit. Administrator Paul Oseso was not present, however Administrator certificate is current. LPA's toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and outdoor spaces. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. First Aid/CPR certification was current. Medications were also reviewed. LPA's followed up on two Unusual incident reports submitted by facility on 05/22/2024 and 06/20/2024. The incident reports were in regards to two different medication errors. This is the forth violation of the same code section within a 12 month period. ******* An immediate civil penalty is being issued in the amount of $1000.00.******* The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required seven-day non-perishable and two day perishable supply of food. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguishers were fully charged. Facility has fire sprinklers throughout. Smoke detectors are all operational. Carbon Monoxide Detectors were present. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. Facility has been conducting drills every 3 months. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Evidence of control of property LIC500- Personnel Report Evidence of Liability Insurance Continued on LIC809-C... Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Myrene Gaeta and Appeal rights were given.the state’s words, verbatim · CDSS document, Jul 23, 2024

Type of visit: Case Management - Incident

At approximately 11:40 AM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a Case Management Inspection on Incident Reports dated 01/14/2024 that were received by Community Care Licensing (CCL) on 01/22/2024. LPA met with General Manager (GM), Paul Oseso and Health Services Director (HSD), Lady Tsang. Incident Report #1: Incident report states that Resident 1 (R1) had an order for Amoxicillin which was prescribed with instructions to give two capsules by mouth twice daily for five days beginning on 1/8. Medication Technician noticed that R1's Electronic Medication Administration Record (EMAR) no longer had an order for Amoxicillin but there were two capsules left in the bottle. The discrepancies in the EMAR and the bottle of medication appeared to be a result of missing a dose of medication, resulting in the facility sending CCL an incident report. Per conversation with GM and HSD, the medication was prescribed as a 5 day dose, and MAR and EMAR reflect that it was given for 6 days, then it is noted on the EMAR that the last dose was given on 1/14, reaching a total of 7 days. The medication was started on a paper MAR on 1/8/24 and then was continued onto the EMAR the evening of 1/10. MAR for the evening of 1/8 is marked with a circle. Per conversation, the circle can mean either a missed dose or an "excused miss" which can mean that the medication was given but not marked in the MAR. The medication technician on shift at the time of medication administration confirmed that the medication was passed. At this time, HSD, GM, and LPA concluded that the pharmacy inputted the incorrect instructions for the medication to be given for five days or accidentally included an additional two days of antibiotics. Continued on LIC809-C Continued from LIC809\ Incident Report #2: Resident 2 (R2)s family member was visiting and informed the nurse that they found an unknown capsule on R2's coffee table. The capsule was found to be Tamiflu. It was unknown if the capsule was from the mornings medication pass or from a previous medication pass. The medication was given on the next scheduled medication pass. The resident did not have any adverse affects. Per conversation with GM and HSD, R2 is cognitively aware. It is believed that the Medication Technician poured the medications and was confident that R2 would remember to take them. The Medication Technician then left R2 to take their meds without checking to make sure they were consumed. LPA was provided with proof of medication training that has been conducted since the incidents. HSD and GM informed LPA of another upcoming medication training that is scheduled to be conducted on 02/06/2024. LPA is requesting staff attendance sign in sheet from scheduled training, as well as what topics are to be covered once the training is conducted. **A Civil Penalty in the amount of $250.00 is being issued today due to a repeat violation of Regulation 87465(a)(4) within a 12-month period.** Exit interview conducted. Copy of report, LIC809D, LIC421FC, LIC 811, Plan of Corrections, and Appeal Rights discussed and provided. Signature on forms confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 1, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 2, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. ... (4)The licensee shall assist residents with self-administered medications as needed. This requirement was not as evidenced by: Based on record review, the licensee did not comply with the section cited above by not ensuring that the medications were given as prescribed.the state’s words, verbatim · CDSS document, Feb 1, 2024

Plan of correction: ED and HSD have conducted medication training since the incidents. There is additional medication training to be conducted the week of 02/04/2024. LPA to be provided with proof of training as well as topics covered once conducted. Deficiency cleared during visit.

Type of visit: Case Management - Incident

At approximately 9:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to several incident reports submitted to CCL ranging from October thru December 2023. LPA met with Executive Director Paul Oseso, reviewed records and interviewed staff. Incident 1: On 10/05/2023, staff observed the same medication, Quetiapine 25mg, was entered into their computer system twice, thus R1 was being given the medication twice daily instead of only once a day from 09/26-10/04/2023. An investigation was conducted and found that one nurse had entered the medication into the system manually. The normal procedure is to not enter medications manually. The medication orders are sent to the pharmacy, which updates the system. Retraining was conducted for nurses on the process of confirming medications in their system. Retraining was conducted on how to handle and report medication incidents. Incident 2: CCLD received a self reported SOC341, Report of Suspected Dependent Adult/Elder Abuse, on 10/11/2023. The report described an incident between two residents. Staff heard an altercation in the hallway and observed resident, R2, push resident, R3, to the ground and kick them. Staff separated residents and assessed them for injury. LPA reviewed resident care plans and found notes regarding resident behaviors and how staff should react. Training has been conducted on combative behaviors and how to report incidents. Staff followed their procedures and there were no injuries to resident. Incident 3: On 12/27/2023, CCLD received an incident report regarding a resident that did not receive 2 of 6 daily applications of a medication from 12/11-23/2023. The medication order was put into the system to administer the medication during the night time hours, but the medication technician was not informed. Physician was notified and the dosing schedule was updated. Continued on LIC 809-C... Training has been conducted to address communication between nurses and medication technicians. ***This is a repeated violation of the same regulation section in a 12 month period. An immediate civil penalty is being issued in the amount of $250.*** Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Paul Oseso and Appeal rights were given.the state’s words, verbatim · CDSS document, Jan 2, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jan 3, 2024

87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure resident received medication as prescribed by Physician. This poses an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 2, 2024

Plan of correction: Licensee conducted retraining for all Nurses and Medication Technicians on communications between nurses and staff and working with their computer system. POC cleared at time of visit.

Type of visit: Case Management - Incident

At approximately 11:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a case management visit in regards to an incident report submitted to CCL on 08/21/2023. LPA met with Business Office Manager Eugene Pascual. The details of the incident report was a report of a medication error that occurred on 08/15/2023. Medication technician on duty signed off that they had administered the medication, but the pill was found to still be in the package. Interviews conducted by the facility with the medication technician found that during the medication pass, staff became distracted and might have taken the pill from a different residents supply, or signed that the pill was given without actually doing so. Staff was provided retraining in the administration of medication and has completed a review of facility procedures. LPA received copies of completed training verification. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Eugene Pascual and Appeal rights were given.the state’s words, verbatim · CDSS document, Oct 2, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 3, 2023

87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure resident received the correct medication as prescribed by Physician. This poses an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 2, 2023

Plan of correction: Responsible staff was given retraining on medication administration. POC cleared at time of visit.