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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 03:51:04 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:
02:50 PM
MET WITH:Interim Administrator Donal Stamets and Health Services Director Whitney Justus.TIME COMPLETED:
03:20 PM
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On 4/1/2022 At 3:00 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.

LPA interviewed Health Services Director Whitney Justus regarding SOC 341/incident report that was submitted on 3/22/2022 by facility.

On 3/14/22 at approx. 5pm a staff (S1) witnessed S2 allegedly "aggressively" put resident (R1) into dining room chair by placing S2's hands on R1's waist. S2 was immediately sent home by management. Nurse assessed resident for injuries, none found. No distress noted. Law enforcement report taken and attached to LIC 812.

Staff member has been documented with a written warning, further dementia training has been given and will have a two week follow-up regarding performance of education and training.

Resident was immediately back at baseline following the alleged 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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