216803029-5-4-2022-21-AS-BMOS-CE6LG6-20220506084410

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803029
Report Date: 05/04/2022
Date Signed: 05/04/2022 10:11:48 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2022 and conducted by Evaluator Shannan Hansen

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220112130233

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: 111	DATE:	05/04/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	General Manager Gary Goroyan		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Staff do not have required training

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with General Manager Gary Goroyan as Interim Administrator Donald Stamets was out.

Staff do not have required training – It is alleged there is not enough training in the kitchen or for caregiving. Based on LPAs records review of facility kitchen staff trainings, it was revealed through a random sample that kitchen staff had 4 out of 4 food handler certificates (valid from 3/2021 through 5/2024) that are up to date. Based on record review of staff training provided by General Manager it was revealed that training for 5 out of 8 care giving staff for 2021 could not be provided. General Manager informed LPA via email that training for 5 (S1, S2, S3, S4 & S5) staff requested could not be located and staff training will begin next week. Therefore, required staff training has not been met per the regulation.
The preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights given.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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 4

Control Number 21-AS-20220112130233

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AEGIS ASSISTED LIVING OF CORTE MADERA	FACILITY NUMBER: 216803029
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/20/2022 Section Cited HSC 1569.625	1 2 3 4 5 6 7	1569.625 Staff training; legislative findings; contents: training requirements. This requirement is not met as evidenced by: Based on file review & interview with Administrator/General Manager, the facility failed to ensure that staff had completed the required initial & continued annual training as	1 2 3 4 5 6 7	Administrator to submit proof of required care giver trainings with names, signatures, dates and topics covered. Updated trainings to be submitted to CCL by POC date of 5/20/22
	8 9 10 11 12 13 14	required by regulations which poses a potential health and safety risk to residents in care. Licensee was unable to provide documentation that 5 of 8 (S2 S3 S5 S7 S8) staff had completed the required training.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2022 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20220112130233

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:	DATE:	05/04/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	General Manager Gary Goroyan		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Facility does not have sufficient staff resulting in resident care needs not being met
Residents are not treated with dignity
Food service is inadequate
Medication management is inadequate
Facility is unsanitary

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with General Manager Gary Goroyan as Interim Administrator Donald Stamets was out.

Facility does not have sufficient staff resulting in resident care needs not being met – Complainant alleges that facility is short staffed and due to short staffing residents are getting injured. Residents fall and are left on the floor and those that fall will sometimes die a short time after. LPA conducted interviews with residents and staff, reviewed records, and made observations during the investigation on 1/20/2022 & 2/17/2022. Based on LPAs investigation of incident reports and interviews, injuries from falls were not due to insufficient staff. Record review of staff schedule revealed facility has four caregivers on night duty with one med-technician along with nine caregivers and 4 med-technicians on day shift which appears to be sufficient for residents in care. LPA was unable to obtain additional information to support facility has insufficient staff. Therefore, this allegation is unsubstantiated.
Continue on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

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 4

Control Number 21-AS-20220112130233

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AEGIS ASSISTED LIVING OF CORTE MADERA	FACILITY NUMBER: 216803029
	VISIT DATE: 05/04/2022

NARRATIVE

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Residents are not treated with dignity – Complainant alleges residents are treated “horribly”. LPA conducted multiple interviews with residents and made observations on 1/20/22022 & 2/17/22. Residents stated, “we are treated with respect” and “very well”. Based on LPA’s interviews and observations although the complainant alleges facility is treating the residents horribly LPA was unable to obtain proof to support allegations. Therefore, this allegation is unsubstantiated.

Food service is inadequate – Complainant alleges food is not nutritious and residents complain regularly about it. LPA conducted unannounced visits and observed the facility kitchen that included refrigerators/freezers/non-perishable foods. As well obtained copies of 8 weeks of facilities menus and conducted interviews with residents. Based on LPA’s interviews with residents, record review, and observations although the complainant alleges facility food is inadequate LPA was unable to obtain information to support allegations. Therefore, this allegation is unsubstantiated.

Medication management is inadequate – Per reporting party it is alleged that the nurses are short staffed, and they do not have time to hand out pain medications. Residents are turned away from the nursing station rudely, saying they do not have time or “go back to your room”. Based on LPAs observation, record review, and confidential interviews (1/20/2022 & 2/17/2022) with staff, residents in care, and information received from administrator which was consistent but conflicting with what reporting party states, LPA was unable to either prove or disprove the above allegation. Therefore, this allegation is unsubstantiated.

Facility is unsanitary –Complainant indicates resident rooms are unsanitary. On 1/20/22 & 2/17/22 LPA conducted unannounced visits to the facility and observed 6 out of 7 rooms to be clean and sanitary with no odor. One room was observed to have clothes and paper on the floor however resident confirmed they clean their own room and refuse assistance from staff. LPA was unable to obtain information to support residents are left in rooms that are dirty. Therefore, this allegation is unsubstantiated.

Although the allegations above 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: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC9099 (FAS) - (06/04)

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