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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803029
Report Date: 12/23/2020
Date Signed: 12/30/2020 11:32:52 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2020 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20200908121750
FACILITY NAME:AEGIS ASSISTED LIVING OF CORTE MADERAFACILITY NUMBER:
216803029
ADMINISTRATOR:KAUFMANN, LEE E.FACILITY TYPE:
740
ADDRESS:5555 PARADISE DRIVETELEPHONE:
(415) 927-4200
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY:150CENSUS: DATE:
12/23/2020
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Lee KaufmannTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
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8
9
Staff not ensuring resident's care needs are being met.

Staff did not inform resident's authorized representative of changes in resident's health.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold contacted Executive Director Lee Kaufmann to deliver investigative findings for the above allegations. This visit is being conducted by telephone due to Covid-19 precautions. Based on a review of records and interviews conducted, the facility followed regulation in meeting the needs of residents. Facility has monthly weight records for each resident and promtly contacts physician or emergency personnel as needed and documents in residents record. Facility documents and reports to CCL and responsible parties per regulation.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
No citations issued during today's visit.
Original signature on file.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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