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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803029
Report Date: 09/30/2021
Date Signed: 10/04/2021 09:52:52 AM

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:
4159274200
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY:150CENSUS: 103DATE:
09/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Whitney Justus LVN Health Services DirectorTIME COMPLETED:
03:00 PM
NARRATIVE
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On 9/30/3031 LPA Hansen conducted a follow up visit on an incident report that occurred on 9/22/2021, where R1 was eating dinner in the main dinning room and a care staff noted R1 choking, and having difficulty breathing. Nurse was summoned immediately and performed Heimlich. The nurse managed to clear two pieces of food from airway. R1's breathing improved however, respiratory distress still noted and low o2 sat of 86%. Resident was taken to Kaiser ER for further evaluation

LPA Reviewed records and interviewed Nurse. Food provided that day (chunks of chicken) was not in compliance with mechanical soft diet. LPA verified through a records review, per Hospice notes dated 2/18/2021 that R1 identifies the need for a mechanical soft diet which was not what R1 was served.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/01/2021
Section Cited

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87555(b)(7) General Food Service Requirements: The following food service requirements shall apply. Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by: ****Based on observation & record review by LPA & Licensee
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Licensee failed to ensure that (R1) resident was receiving a modified diet as prescribed by their Dr. Staff was observed to have served chuncked chicken to resident R1 who's Hospice Medical Orders identifies that they are on a mechanical soft diet. Diet as tolerated for pleasure and comfort with hectar thick liquids.
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Proof of training to be submitted by 10/11/2021

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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2021
LIC809 (FAS) - (06/04)
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