<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803994
Report Date: 04/11/2023
Date Signed: 04/11/2023 02:07:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2023 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20230202120218
FACILITY NAME:AEGIS LIVING CORTE MADERAFACILITY NUMBER:
216803994
ADMINISTRATOR:STAMETS, DONALDFACILITY TYPE:
740
ADDRESS:5555 PARADISE DRIVETELEPHONE:
(415) 483-1399
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY:150CENSUS: 116DATE:
04/11/2023
UNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Donald Stamets, AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not respond timely to the resident’s alerts
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing program Analyst (LPA) Hansen arrived unannounced to deliver findings regarding the above complaint allegation and met with Administrator, Donald Stamets.
Staff do not respond timely to the resident’s alerts – Complaint alleges that staff are not responding to pendants being pushed, in a timely manner due to lack of staffing. Per interview and email received 4/10/2023 with Administrator, designated timeframe of when call buttons are to be responded to by staff is a 10-minute standard. SMARTcare report obtained from 1/23/2023-2/3/2023 reflect at least three hundred and one response times between 10-30 minutes, and at least 37 response times between 30-60 minutes. Based on LPA’s interviews conducted and a review of call log records, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.
A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20230202120218
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2023
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
87411(a) Personnel Requirements – General- (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on LPA interview’s and record review facility has delayed call response for residents using their pendants.
1
2
3
4
5
6
7
Administrator to ensure staff training on time management, buddy system and concierge coverage to alert approaching alloted time of bells is near are in place to meet the needs of residents. Training schedule of type due to CCL by 4/12/23 Sufficient training for staff on required time response due to CCL by COB 4/20/2023.
8
9
10
11
12
13
14
From1/23/2023-2/3/2023 reflect at least three hundred and one response times between 10-30 minutes, and at least 37 response times between 30-60 minutes. This is an immediate risk to the Health, Safety and Personal Rights of residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/02/2023 and conducted by Evaluator Shannan Hansen
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230202120218

FACILITY NAME:AEGIS LIVING CORTE MADERAFACILITY NUMBER:
216803994
ADMINISTRATOR:STAMETS, DONALDFACILITY TYPE:
740
ADDRESS:5555 PARADISE DRIVETELEPHONE:
(415) 483-1399
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY:150CENSUS: 116DATE:
04/11/2023
UNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Donald Stamets, AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not meet the residents hygiene needs while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing program Analyst (LPA) Hansen arrived unannounced to deliver findings regarding the above complaint allegation and met with Administrator, Donald Stamets.

Staff do not meet the resident’s hygiene needs while in care – Complaint alleges that residents have complained that staff are not bathing them. RP did not provide contact information and LPA was unable to obtain additional specific information relevant to this allegation. Per LPA’s observation of residents on 2/7/2023, 3/22/2023, and 3/16/2023, interviews conducted with resident’s and staff, and record reviews of shower logs did not indicate staff do not meet the resident’s hygiene needs while in care, were unsubstantiated, meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegation occurred.
Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3