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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803029
Report Date: 04/01/2022
Date Signed: 04/01/2022 03:51:48 PM


Document Has Been Signed on 04/01/2022 03:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 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: 113DATE:
04/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:21 PM
MET WITH:Interim Administrator Donald Stamets & Health Services Director Whitney Justus LVNTIME COMPLETED:
03:50 PM
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On 4/1/2022 at approximately 3:15 pm while already at facility conducting pre-licensing inspection, Licensing Program Analyst (LPA) Hansen conducted a case management regarding an SOC 341 that facility submitted on 3/28/22. The purpose of the case management visit is to follow up on incident report submitted by the facility and to conduct interviews.

On 3/25/2022 at approximately 6:15pm staff heard a commotion downstairs in the hallway adjacent to the dinning area. At which point two residents were having a verbal altercation which turned into be physical where one resident pushed one resident to the floor. Although said resident admitted later, R 1 didn't intend to make R2 fall but it happened.

Both residents were assessed and both were not in any type of distress. Neither residents were found to have any injuries immediately or there after from said altercation. Later R1 informed Health Services Director that the incident was caused by an earlier issue at the elevator when R1 did not hold the elevator door for R2.

Health Services Director has informed all staff have been made aware to insure residents avoid interaction. R2 has the onset of dementia. Nursing team preformed daily check-in for the following 72 hours without incident.

No citations issued during todays visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/01/2022
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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