216803994-10-26-2023-21-AS-BMOS-CX6TPS-20231101145449

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803994
Report Date: 10/26/2023
Date Signed: 10/26/2023 10:08:46 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
08/09/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20230809124148

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: 108	DATE:	10/26/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Nithi Narasappa, Director of Operations/Interim Administrator		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Personal Rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Nithi Narasappa, Director of Operations/Interim Administrator.

During complaint investigation LPA conducted interviews with 3 staff and 3 residents, made observations at facility on 8/15/2023 & 9/7/2023 and reviewed records.

Personal Rights – Complainant alleges staff does not provide assistance to resident when needed. Reporting Party (RP) stated when R1 needs assistance S1 does not pay attention to R1. No other details provided to RP from R1. Review of staff records confirmed training per regulation for S1. S1 is a long-term staff and interviews with S2 and Administrator did not reveal staff does not provide assistance to resident when needed.
Continue on LIC9099-C

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: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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-20230809124148

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: 10/26/2023

NARRATIVE

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Documents obtained from facility records also indicate S1 does provide daily care needs to R1 of their individualized service plan. LPA’s interview with R1 did not reveal additional information regarding needs not being met.
Complainant alleges staff yelled at resident, although complainant states they did not witness this event. Per reporting party (RP) R1 stated S1 made a derogatory comment in a “public setting”. R1 did not specify if it was staff members or residents. RP stated they believe S1 yelled at R1 when making that comment. LPA interviewed 3 residents who have stated all care staff have treated them very well and have no complaints. Interview with Administrator on 8/15/2023 revealed S1 has never had any issues with residents or have had any write ups. During this investigation there has been no evidence found indicating S1 has yelled at a resident in care.
Complainant alleges staff made inappropriate comments to resident. RP alleges S1 made a comment to R1 in a public setting indicating they have an incontinence problem. RP also indicated in mid-June 2023, R1 was having digestion issues and had accidents with stool. Interviews with Administrator and S1 revealed the conversation took place in the private living space of R1 and was a miscommunication regarding accidents. Interview with R1 revealed there were comments made about incontinence issues in the apartment and none since. Interview conducted on 10/16/2023 with outside party revealed no concerns regarding facility staff. Based on LPAs observations, record review, and confidential interviews (8/15/2023 & 9/7/2023) with staff, residents in care, and information received from administrator which was consistent but conflicting with what reporting party states, LPA was unable to either prove or disprove the above allegations. Therefore, this allegation is Unsubstantiated.
Although the allegations above 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 allegations are unsubstantiated.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC9099 (FAS) - (06/04)

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