216803029-4-26-2022-21-AS-BMOS-CEJNX4-20220518105032

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803029
Report Date: 04/26/2022
Date Signed: 04/26/2022 09:36:11 AM

Unsubstantiated

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
02/22/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20220222142645

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: 116	DATE:	04/26/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Donald Stamets		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Did not observe change of condition for resident causing hospitalization
Facility staff not responding to call for service in a timely manner
Facility did not follow reporting requirements to Responsible Person

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Administrator and discussed the findings. In response to the above captioned allegations this Department has taken statements, reviewed documents, and made four site visits. The following determinations are made: Records show that all known incidents involving R1 were reported timely in compliance with 87211; R1 states no issues with response times for calls for service; Facility's Service Summary Log for period 2/18 thru 2/20/2022 indicates 20 service visits by staff to R1's room; R1 became symptomatic on 2/19 and when condition worsened R1 was sent out on 2/20/2022; Complainant alleges that R1 should have been sent out on 2/19 or earlier on 2/20; Records and statements support that a assessment was done by facility nurse on 2019 with findings reported to physician who ordered continued observation, increased hydration and close monitoring; Statements from attending 911 medics have not been made available for review. Although the allegations may be true, based on documents and statements, there is not a preponderance of evidence to prove or disprove allegations. Therefore, the complaint is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

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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