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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803029
Report Date: 09/22/2021
Date Signed: 09/30/2021 02:54:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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: 103DATE:
09/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:53 AM
MET WITH:Whitney Justus LVN Health Services DirectorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection. LPA arrived to the facility and met with Whitney Justus LVN Health Services Director. The purpose of this case management inspection is to follow up on a self reported incident report submitted to Community Care Licensing (CCL) on 9/16/2021.

LPA has asked questions, and requested more information for residents - see LIC 812s.

No deficiencies cited during todays inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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