216803029-10-14-2021-21-AS-KMOA-C9XPUB-20211222103714

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803029
Report Date: 10/14/2021
Date Signed: 10/14/2021 10:02:40 AM

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
09/15/2021 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20210915103908

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:	10/14/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Interim Administrator - VP of Operations Development Bill Phelps		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not seeking medical treatment for resident in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 10/ 14/ 2021 at approximately 9:30 AM Licensing Program Analyst Shannan Hansen arrived unannounced to deliver findings regarding the above complaint allegation and met with Interim Administrator Bill Phelps. Administrator Lee Kaufmann has been promoted and VP of Operations Development Bill Phelps is the Acting Administrator until a new Administrator is hired.

Staff are not seeking medical treatment for resident in care – Complaint alleges that resident, R1 was not properly being treated for a hurt shoulder. LPA reviewed medical progress records, facility notes, conducted interviews and made observations. Evidence does not support allegations that resident sustained an injury.

A finding of the complaint allegation that facility failed to ensure health and safety of resident in care was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

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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