216803994-6-14-2022-21-AS-BMOS-CFUTYZ-20220629150933

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803994
Report Date: 06/14/2022
Date Signed: 06/14/2022 01:42:00 PM

Substantiated

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
05/27/2022 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20220527104945

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: 115	DATE:	06/14/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Donald Stamets - Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility failed to administer medication per physicians’ orders

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen made an unannounced subsequent visit to the facility. The purpose of this visit is to deliver findings for the above allegation. LPA met with Administrator Donald Stamets.

Complaint alleged that facility failed to administer R1’s medication per physicians orders. Per reporting party, R1 notified staff at facility about shortness of breath/asthma but was not given medication and called 911. Record review of physician report (dated 4/2/22) revealed R1 has asthma and requires assistance administering prescription medications and PRN (as needed) medications. Primary care physician orders/email of (5/31/2022) show R1 has daily scheduled preventative medications and also PRN medications if R1 feels wheezy or short of breath. Interviews, nursing notes, and document from Administrator revealed on 5/26/2022 at approximately 7:28pm R1 called facility front desk stating, “having an asthma attack”. Nurse responded, assessed, and informed R1 medication would be brought. Simultaneously, there was a second resident that had fallen and needed immediate attention, nurse called medication care manager (MCM) and instructed to bring and assist R1 with medication.
Continued on 9099C

Substantiated

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: 06/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

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-20220527104945

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: 06/14/2022

NARRATIVE

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MCM brought medication to room but was unable to locate medication mask in R1’s room to administer and unable to find replacement on med cart. MCM left room to request direction from nurse. Approximately 20 minutes later nurse returned to R1’s room finding R1 had called 911. R1 returned from hospital to facility same day. Documents obtained dated 6/1/2022 from Administrator, MCM could have informed R1 when leaving the room, what the plan was and could have offered the inhaler instead. The facility has since purchased an extra mask for the medication cart and conducted a mandatory Inservice training on 6/1/2022 for nursing team and all MCM’s regarding asthma, asthma triggers, asthma medication and interventions.The preponderance of evidence standard has been met: therefore, the above allegation is found to be Substantiated.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220527104945

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/15/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The facility conducted a staff training on 6/1/2022 to address the situation with locating R1s mask to administer PRN medication timely. LPA obtain a copy of training sign in sheet at time of inspection, Citation cleared 6/14/2022.
	8 9 10 11 12 13 14	Based on interviews and record reviews, the licensee/Administrator did not ensure staff was competent and or knowledgeable to be able to administer per doctor orders. Staff could not find the mask needed which is an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

LIC9099 (FAS) - (06/04)

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