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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803994
Report Date: 07/06/2023
Date Signed: 07/06/2023 09:11:46 AM

Unsubstantiated


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
06/07/2023 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20230607095941
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: 118DATE:
07/06/2023
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH: Nithi Narasappa, Director of OperationsTIME COMPLETED:
08:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility kitchen is dirty
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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.

Facility kitchen is dirty - On 6/15/2023 & 6/20/2023 LPA conducted unannounced visits to facility. LPA toured the kitchen and observed meals being prepared and the kitchen, floors, countertops clean (see Pics LIC812). LPA was informed by reporting party during interview, allegation was from a third party and reporting party was not sure of validity. Based on observations & interviews there is insufficient information to prove or disprove the allegation 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.
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: 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: 1 of 2
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
06/07/2023 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20230607095941

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: 118DATE:
07/06/2023
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH: Nithi Narasappa, Director of OperationsTIME COMPLETED:
08:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was overdosed due to staff neglect
Staff are not keeping track of when resident's medication was administered
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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.
Resident was overdosed due to staff neglect – Complaint alleges resident (R1) had been given PRN Tylenol in too many doses in a short period of time. Record review of R1’s medication records confirms R1 is prescribed PRN (taken as needed every six hours) Tylenol and that R1 was not given medication outside of the prescribed dosage. LPA interviewed staff who confirmed when any medication is provided to residents it is logged in a system. LPA was able to confirm per record review that Medication passing details, obtained from facility shows date, time, and initials of staff who provided PRN medication for date in question. Therefore, the allegation, “Staff are not keeping track of when resident’s medication was administered” is also UNFOUNDED.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 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: 2 of 2