216803994-4-1-2022-21-AS-SHAN-CD3TJH-20220401144623

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803994
Report Date: 04/01/2022
Date Signed: 04/01/2022 02:46:53 PM

Document Has Been Signed on 04/01/2022 02:46 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 LIVING CORTE MADERA		FACILITY NUMBER:	216803994
ADMINISTRATOR:	STAMETS, DONALD		FACILITY TYPE:	740
ADDRESS:	5555 PARADISE DR		TELEPHONE:	4154831399
CITY:	CORTE MADERA	STATE: CA	ZIP CODE:	94925
CAPACITY:	150	CENSUS: 113	DATE:	04/01/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Donald Stamets & Vice President of Regulatory Affairs Ana de la Cerda		TIME COMPLETED:	09:31 AM

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License Program Analyst (LPA) Hansen arrived at 9:00 AM to conduct an unannounced pre-licensing inspection and was greeted by Donald Stamets, Administrator and Ana de la Cerda, Vice President of Regulatory Affairs, & Gary Goroyan a General Manager of Aegis. This is a change of ownership. LPA signed in and filled out electronic intake form and had temperature checked by electronic system. Fire clearance has been approved for 150 non-ambulatory residents, of which 35 may be bedridden, by the County Fire Department. Approval for Hospice Waiver of 25. LPA conducted a component III orientation with Donald Stamets, Administrator. There is a total of 113 residents, 34 dementia residents, and 11 residents under Hospice care.

Facility tour/inspection began at 9:30 AM:

Beginning at approximately 9:30 AM, LPA toured the community with Administrator Donald Stamets and Vice President of Regulatory Affairs Ana de la Cerda. The tour of the facility included the resident apartments, activity rooms, Library, Salon, dining rooms, kitchen and outdoor patios. All interior parts of the facility were found to be a comfortable temperature measuring between 75 to 78 degrees F. Exits and pathways were free from obstructions. The assisted living residents also have an outdoor patio courtyard. Egress doors from the memory units (Lee’s Lane & Hogan’s Court) have audible alarms when doors are opened without access codes. The front door and main exits from the assisted living area also have audible Wanderguard system. Hot water temperature measured 111.0, 111.5, 111.9, 113.0, 113.4, 115.8, 116.2, 116.5, 116.6, & 118.4 degrees F in faucets used by residents which falls within regulation of 105 to 120 degrees F. Bathrooms contained necessary grab bars and shower contained non-slip floor/mats. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for residents in care. Food was found to be handled and stored in a safe manner. Dining rooms and kitchen were inspected and well maintained. Menus and snack and beverages are available to residents and family. Activity schedules are posted. Facility has a theater and multiple indoor and outdoor sitting areas and a private dining area for residents and visiting families for special occasions. Facility also has 5 apartments with electric fireplaces.

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SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 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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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 LIVING CORTE MADERA	FACILITY NUMBER: 216803994
	VISIT DATE: 04/01/2022

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Emergency disaster drills are conducted monthly during different shifts with the last Disaster Drill conducted on. Fire extinguishers were current and charged as of 3/1/2022. Fire safety system including smoke detectors and carbon monoxide detectors are checked quarterly. Smoke detectors are hardwired on the first & second floors and in all common rooms and hallways. Carbon monoxide detectors were observed to be working at the time of the visit.

In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the first-floor storage closet. Staff have had all PPE training required on file and been N-95 fit tested.

Pre-Licensing is complete, and this facility has no apparent deficiencies. Facility is ready for licensure.

LPA will conduct record review and medication review during Post Licensing

Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation. LPA will notify Application Unit Pre-licensing inspection is complete to proceed with process.

There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 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

LIC809 (FAS) - (06/04)

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