216803994-8-3-2023-21-AS-HDBI-CUKNWY-20230810105016

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803994
Report Date: 08/03/2023
Date Signed: 08/03/2023 09:25:56 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
06/15/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20230615084005

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:	08/03/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Rukhshana Shah, Business Office Manager		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Resident 's personal rights were violated by staff while in care

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 Business Office Manager Ruksshana Shah, Administrator, Donald Stamets was out of the facility.
During investigation LPA reviewed documents obtained including Police Report and conducted interviews with resident (R1) and staff regarding allegation. Complaint alleges that resident was inappropriately touched by staff. Interview with R1 revealed that resident was unable to confirm alleged event due to confusion. R1 was sent out on 6/10/2023 to emergency room due to observed vaginal bleeding. It was determined at the hospital R1 had a urinary track infection. Additional information obtained during investigation does not support a violation occurred. Police report obtained indicates no further action and is closed.

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: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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-20230615084005

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: 08/03/2023

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 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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC9099 (FAS) - (06/04)

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