216803994-11-13-2023-21-AS-BMOS-CXLQ6G-20231115105331

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803994
Report Date: 11/13/2023
Date Signed: 11/13/2023 09:53:26 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
08/14/2023 and conducted by Evaluator Shannan Hansen

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230814125522

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: 106	DATE:	11/13/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Nithi Narasappa, Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff are locking residents in their rooms
Resident care needs are not met resulting in pressure injuries

INVESTIGATION FINDINGS:

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

During complaint investigation LPA conducted interviews with 4 staff and outside individual, made observations at facility on 8/15/2023 & 10/26/2023 and reviewed records.

Staff are locking residents in their rooms- Complainant alleges another individual informed, residents in the memory care are locked in their rooms any time they are in their rooms and when inquired, response was, locking memory care residents is legal as this keeps residents from wandering out. LPA observations of facilities memory care unit on 10/26/2023 revealed five of ten apartment doors checked were locked, with residents in the five rooms.
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: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

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-20230814125522

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: 11/13/2023

NARRATIVE

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LPA’s interview with Administrator Nithi Narasappa and staff (S1) revealed, in the memory care units, residents who are able to go in and out of their rooms on their own do not have their doors locked when they are in them. Residents who are in wheelchairs and unable to get up on their own have their doors locked when they are in their rooms so other residents who have challenging behaviors do not go into these residents’ rooms or interrupt them and only have to push the door handle down to open if resident is inside. LPA observed locking system on door to ensure any resident that has the capability of leaving, through door, which can be freely opened by any resident residing in the room. Interview on 11/6/2023 with senior general manager revealed facility policy in memory care is to conduct continuous 2-hour room checks on the residents who are in/use wheelchairs and are behind locked doors.
Based on LPAs observations, record review, and confidential interviews (8/15/2023, 10/26/2023 & 11/6/2023) with staff, outside individuals, and information received from administrator, LPA was unable to either prove or disprove staff were locking residents in their rooms with the intent of resident not to be able to exit on their own will. Therefore, this allegation is Unsubstantiated.

Resident care needs are not met resulting in pressure injuries- Complainant alleges another individual informed there are unknown pressure sores on a resident. LPA conducted record review and interviews with outside parties, staff, and medical professionals that revealed R1 was seen by an outside medical professional (Hospice Nurse) since December 2022 and informed in July 2023 R1 had pressure injuries to both heals. LPA’s interviews with staff confirmed knowledge of R1’s care plan and it appears care plan is being followed. In August 2023 a pressure injury to the buttocks was noted on R1 and with staff following doctors’ orders is almost healed. Interviews with Medical professional did not reveal concerns regarding R1’s care needs are not being met. Progress notes for R1 indicates same findings as interviews. Based on LPAs observations, record review, and confidential interviews with staff, outside individuals, and medical professionals, LPA was unable to either prove or disprove resident care needs were not met resulting in pressure injuries. 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: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC9099 (FAS) - (06/04)

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