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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803994
Report Date: 06/15/2023
Date Signed: 06/15/2023 11:23:47 AM


Document Has Been Signed on 06/15/2023 11:23 AM - 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 MADERAFACILITY NUMBER:
216803994
ADMINISTRATOR:STAMETS, DONALDFACILITY TYPE:
740
ADDRESS:5555 PARADISE DRIVETELEPHONE:
(415) 483-1399
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY:150CENSUS: 116DATE:
06/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Donald Stamets, AdministratorTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Shannan Hansen arrived unannounced at Aegis Living Corte Madera for the purpose of following-up on an incident report that was forwarded to the Regional Office (RO). LPA met with Administrator Donald Stamets.

CCL received a self reported incident report from facility reporting 13 medication errors. The errors occurred on the evening of 06/07/2022 while medication care manager (S1) was dispensing medication. R1-R13 were not given prescribed evening medications during medication passing as prescribed by physicians. S1 passed all other medications for the evening to assisted living residents and neglected to finish. Medication error was discovered by Dir. Of Operations in AM report on 6/8/2023 at 8:00am and reported to nursing to conduct 72 hr alert charting and monitor for adverse effects for R1-R13. Responsible parties and prescribing doctors were notified of medication error. Medication trainings have been conducted and will continue.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..


SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/15/2023 11:23 AM - 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 LIVING CORTE MADERA
FACILITY NUMBER: 216803994

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2023
Section Cited
CCR
87465(a)(5)

1
2
3
4
5
6
7
87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed.
1
2
3
4
5
6
7
POC- Administrator agrees to submit log of in-service additional training regarding medication handling by POC due date, 6/15/2023.
Director of Operations has informed Med Tech on duty has been provided numbers to contact if unable to complete med pass ..
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on record review and interview with Director of Operations, the facility failed to ensure R1-R13 medications were given as prescribed by doctor (not provided at evening med pass) which poses an immediate health and safety risk to resident in care.
8
9
10
11
12
13
14
 alone and with all other med tech’s has received training on policies & procedures of Med pass routine & will continue medication training 1 day per week for 3 more weeks after this week.

POC has been cleared at today’s visit.

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: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2