216803994-8-3-2023-21-AS-KMOA-CUJQK9-20230809121359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803994
Report Date: 08/03/2023
Date Signed: 08/03/2023 09:25:08 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
04/06/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20230406084732

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 sustained unexplained injury
Staff mismanaging resident medications
Resident being left in soiled clothing for extended amount of time

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.

Staff mismanaging residents’ medications – Complaint alleges staff did not ensure residents medications were administered or ingested properly. LPA obtained records indicating medication records to be in order. Medication Administration Record (MAR) for February and March of 2023 show resident refused medications, 9 times in February and 19 times in March. Based on interviews with Staff (S1-S2) indicated they were aware of R1’s behavior and issue with taking medication by cheeking the medication and later spitting out unbeknownst to staff. When R1 did cheek the medication staff would sit with R1 and wait and talk to R1 for a while until R1 either spit it out or would swallow it. Sometimes R1 would choke it back up later and staff would find it. While conducting investigation, LPA observed R1 given medication and moments later spit it out, claiming it was a tooth.

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-20230406084732

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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LPA did not find medications on floor. CCL was provided a photo with medications alleged to be found on the ground. LPA did not observe or obtain additional information that medications were being mismanaged. Based on the physician’s report R1 required assistance taking medications due to diagnosis of dementia. Based on LPA’s interviews conducted, a review of Medication Records, and observation, there is insufficient information to prove or disprove staff mismanage residents’ medications. Although it was known resident cheeked medications and 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.

Resident sustained unexplained injury – Complaint alleges resident had fallen out of chair in room and was injured. Resident resides in a memory care unit. Resident’s care notes state on 3/15/23 black and blue area to the right side of head along with some swelling although resident did not remember. Resident’s physician’s report states R1 had rotator cuff tear and osteoarthritis, uses a walker, and has history of falls. Although it is alleged that the resident fell out of a chair in their room and sustained injury, based off of interviews and record review facility documented observed injuries with no witnesses to the incident. Although it was known resident has a history of falls and 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.

Resident being left in soiled clothing for extended amount of time - Residents Service Plan of 3/21/2023 indicates Resident does not need incontinence program and resident is independent in toileting, Physicians report dated 8/11/2022 states Resident is able to care for own toileting needs. While conducting investigation LPA did not observe R1 in soiled clothing on either 4/11/2023 or 6/15/2023. Although it was alleged that the resident was left in soiled clothing for extended amounts of time, 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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