216803029-4-2-2021-21-AS-KMOA-BZTRDJ-20210406125602

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803029
Report Date: 04/02/2021
Date Signed: 04/02/2021 03:44:53 PM

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
11/20/2020 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20201120102929

FACILITY NAME:	AEGIS ASSISTED LIVING OF CORTE MADERA		FACILITY NUMBER:	216803029
ADMINISTRATOR:	KAUFMANN, LEE E.		FACILITY TYPE:	740
ADDRESS:	5555 PARADISE DRIVE		TELEPHONE:	(415) 927-4200
CITY:	CORTE MADERA	STATE: CA	ZIP CODE:	94925
CAPACITY:	150	CENSUS: 106	DATE:	04/02/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Administrator, Lee Kaufmann via Virtual Visit		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility did not seek timely medical treatment for resident.
Resident's call button is not being responded to timely.
Resident is not able to communicate with family by phone.
Facility staff did not notify authorized representative of resident's change in condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi and Licensing Program Manager (LPM), Kimberley Mota conducted a complaint investigation and made contact on this date, by phone, and conducted an unannounced virtual visit with the Administrator, Lee Kaufmann for the purpose of delivering complaint findings and to close the complaint. A in-person complaint investigation inspection could not be done due to COVID-19 precautions.

LPA Sarangi and Ferandes-Goes initiated an investigation beginning on November 25, 2020 at approximately 08:00 AM. During the course of the investigation, LPA's interviewed staff, residents and various outside parties, including but not limited to responsible parties, long term care ombudsman, conducted virtual tour of the facility on 02/01/2021 and reviewed various documents including resident records, facility records, Special Incident Report (SIR), communication records and medical records.

Complaint alleges facility did not seek timely medical treatment for resident (Report continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021

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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Control Number 21-AS-20201120102929

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: AEGIS ASSISTED LIVING OF CORTE MADERA	FACILITY NUMBER: 216803029
	VISIT DATE: 04/02/2021

NARRATIVE

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Based on interviews, review of facility, resident and medical records and email correspondence between facility and R1's responsible party, LPA learned that when R1 began complaining of hip pain R1 physician and responsible party were notified. It was agreed upon by physician, responsible party and facility to have a Mobile X-Ray brought to R1's room in lieu of going to the ED . After a review of R1s X-ray, R1s Dr. recommended R1 be transported to the hospital for a possible displaced hip. Based on Dr. recommendations, facility made arrangement for R1 to be transported to the hospital. As it relates to this allegation, there is insufficient information to prove or disprove the allegation.

Complaint alleges that the residents call button is not being responded to timely. Based on interview with residents, staff and outside parties and a review of resident and facility records including the call button manifest. LPA Sarangi is unable to prove or disprove if there was ever an occasion the staff failed to respond to R1s calls timely. LPA and ED discussed facilities procedures with regarding resetting of call bells.

Complaint alleges that the resident is not able to communicate with the family by phone. Based on interviews with resident, staff and outside parties, LPA learned there are times that R1 does not want to be interrupted by the telephone while watching television and will chose not to answer the phone. In addition, based on observation LPA was able to verify that there is a working phone accessible to R1 at all times. Based on information gathered, LPA was not able to prove to disprove this allegation regarding R1 not being able to communicate with family by phone.

Complaint also alleges that facility staff did not notify authorized representative of resident's change in condition- Based on interviews and a review of facility, resident and medical records, LPA learned that R1's doctor decided based on review of R1’s X-Ray that they should be sent to the Hospital. Upon notification from R1s physician, the facility made appropriate arrangements to have R1 transported to the Hospital. A review of facility records and email communication indicate that R1's responsible party was notified of R1's change of condition in a timely manner.

Based on the interviews that were conducted and the documents/evidence reviewed, the allegations of, Facility not seeking timely medical treatment for resident, Resident's call button is not being responded to timely, Resident is not able to communicate with family by phone, Facility staff did not notify authorized representative of resident's change in condition is Unsubstantiated meaning that although the allegations 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 allegations are Unsubstantiated.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021

LIC9099 (FAS) - (06/04)

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