216803994-7-6-2023-21-AS-HDBI-CTQUR8-20230714154819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803994
Report Date: 07/06/2023
Date Signed: 07/06/2023 09:45:04 AM

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
03/09/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20230309085241

FACILITY NAME:	AEGIS LIVING CORTE MADERA		FACILITY NUMBER:	216803994
ADMINISTRATOR:	STAMETS, DONALD		FACILITY TYPE:	740
ADDRESS:	5555 PARADISE DRIVE		TELEPHONE:	(415) 483-1399
CITY:	CORTE MADERA	STATE: CA	ZIP CODE:	94925
CAPACITY:	150	CENSUS: 118	DATE:	07/06/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Nithi Narasappa, Director of Operations		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff do not answer call buttons timely

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen arrived unannounced at the facility to deliver findings regarding the above allegations. LPA met with Director of Operations, Nithi Narasappa.
During the investigation, the Department conducted interviews, reviewed documents, and made observations.

Staff do not answer calls buttons timely – Complaint alleges that call buttons and call pendant’s are pressed and staff do not respond for over 40 minutes or not at all. 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 3/1/2023-3/20/2023 reflect at least six hundred and fifty-four response times between 10-30 minutes, and at least 66 response times between 30-60 minutes, and at least 43 response times that were more than 60 minutes or never responded to. 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.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230309085241

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
	VISIT DATE: 07/06/2023

NARRATIVE

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This complaint was received in the CCL/RO prior to delivering findings of 4/17/2023 complaint with same allegations. No civil penalties.

The following deficiencies were observed (see LIC 9099D) 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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230309085241

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: 07/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/07/2023 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.
	8 9 10 11 12 13 14	From 3/1/2023-3/20/2023 reflect at least six hundred and fifty-four response times between 10-30 minutes, and at least 66 response times between 30-60 minutes, and at least 43 response times that were more than 60 minutes or never responded to. This is an immediate risk to the Health, Safety and Personal Rights of residents in care.	8 9 10 11 12 13 14	LPA provided copies of traings. POC cleared at time of 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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

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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
03/09/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20230309085241

FACILITY NAME:	AEGIS LIVING CORTE MADERA		FACILITY NUMBER:	216803994
ADMINISTRATOR:	STAMETS, DONALD		FACILITY TYPE:	740
ADDRESS:	5555 PARADISE DRIVE		TELEPHONE:	(415) 483-1399
CITY:	CORTE MADERA	STATE: CA	ZIP CODE:	94925
CAPACITY:	150	CENSUS: 118	DATE:	07/06/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Nithi Narasappa, Director of Operations		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff did not seek timely medical attention for resident
Neglect/Lack of Supervision resulted in resident fall with injury
Staff did not notify authorized representative of incident
Staff not following residents care plan

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen arrived unannounced at the facility to deliver findings regarding the above allegations. LPA met with Director of Operations, Nithi Narasappa.

Records indicate Resident (R2) requested assistance via call button on 3/8/2023 at 3:09am, 4:37am, and 5:47am and staff responded although staff indicated when helping at night (R1 &2) request only one light on to keep the room dark. At 7:45 am Hospice employee arrived to help with shower and noticed the bandage on leg and bruising on the left side of the head. R1 informed the incident had been reported and it was too early to contact RP and R1 would later. (Hospice nurse notes from AM indicate nurse did not notice any bruising or contusions on forehead of patient and laceration to lower extremity during their visit). Per interviews, residents went to breakfast, received medication at 8am and 1pm, attended an event at 11am and at 2pm in the parlor of the community and injury was not observed by staff. At approximately 3pm bruising was reported and Dr. assessed on site. Based on review of records residents does not require one to one supervision.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 21-AS-20230309085241

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
	VISIT DATE: 07/06/2023

NARRATIVE

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Based on LPAs observations, record reviews, interviews with staff, residents and conflicting information obtained from parties, there is insufficient information to prove or disprove the allegations listed above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

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
03/09/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20230309085241

FACILITY NAME:	AEGIS LIVING CORTE MADERA		FACILITY NUMBER:	216803994
ADMINISTRATOR:	STAMETS, DONALD		FACILITY TYPE:	740
ADDRESS:	5555 PARADISE DRIVE		TELEPHONE:	(415) 483-1399
CITY:	CORTE MADERA	STATE: CA	ZIP CODE:	94925
CAPACITY:	150	CENSUS: 118	DATE:	07/06/2023
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Nithi Narasappa, Director of Operations		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen arrived unannounced at the facility to deliver findings regarding the above allegations. LPA met with Director of Operations, Nithi Narasappa.

Facility in disrepair – Complaint alleges the dishwasher is in disrepair and the dining room is dirty. On 3/22/2023 LPA’s conducted an unannounced inspection of the facility and observed (see pics LIC812), the dining room clean. LPA’s inspected the kitchen and observed staff washing dishes during inspection and interviewed Regional Culinary Services Director who informed the dishwasher was working but the sanitizer which sanitizes dishes with hot water was not working and are doing chemical sanitization, therefore the allegation did not occur and is determined to be UNFOUNDED.
This agency has investigated the complaint allegation listed above. We have found that the complaint allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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