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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803029
Report Date: 04/19/2022
Date Signed: 04/19/2022 02:57:07 PM


Document Has Been Signed on 04/19/2022 02:57 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: 115DATE:
04/19/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Executive Director Donald StametsTIME COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Analyst (LPA), Shannan Hansen arrived unannounced at Aegis Assisted Living of Corte Madera for the purpose of following-up on an incident report that was forwarded to the Regional Office (RO). LPA was met by Executive Director Donald Stamets, and was granted access into the facility.

CCL received an incident report reporting a medication error. The error occurred on 04/12/2022 while medication care manager (S1) was dispensing medication. R1 was given the wrong prescribed medication during medication passing. S1 prepared both R1's and another resident's medication in labeled cups and mis-read the cups and had mistakenly given R1 another resident's medication. Medication error was reported to nursing and R1s vitals /allergies checked. Responsible party and prescribing doctor were notified of medication error. LPA obtained copies of the in-house incident report indicating a medication error along with the Medication Assessment Record (MAR) for the month of April 2022 for R1.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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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Document Has Been Signed on 04/19/2022 02:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MADERA
FACILITY NUMBER: 216803029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/20/2022
Section Cited

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87465(a)(5): Incidental Medical and Dental Care Services.The licensee shall assist residents with self-administered medications when needed.

This requirement is not met as evidenced by:
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Based on record review and interview with Administrator the facility failed to ensure R1's medication was given as prescribed by doctor which poses an immediate health and safety risk to resident in care.
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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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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