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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803994
Report Date: 11/30/2023
Date Signed: 11/30/2023 01:35:28 PM


Document Has Been Signed on 11/30/2023 01:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MADERAFACILITY NUMBER:
216803994
ADMINISTRATOR:NITHI NARASAPPAFACILITY TYPE:
740
ADDRESS:5555 PARADISE DRIVETELEPHONE:
(415) 483-1399
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY:150CENSUS: 106DATE:
11/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nithi Narasappa, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Hansen was at facility continuing investigation into a complaint and conducted a case management for a medication error department received. LPA met with Administrator Nithi Narasappa.

On 11/27/2023 Community Care Licensing (CCL) received a self-reported incident report from facility of a medication error that occurred on 11/20/2023. Resident (R1) has an as needed (PRN) prescription for Acetaminophen 500 mg. At approximately 12:45 pm R1 was inadvertently given another resident’s PRN pain medication by staff (S1). Shortly after, S1 realized error and reported to General Manager and Administrator, who notified primary care (PCP) of PRN medication not being given to R1 as prescribed by physician. Responsible party notified. R1 was monitored and had no adverse side effects from other resident’s PRN medication and remains at baseline. Report also indicates policy and procedure review was conducted with staff and an in service training on Medication Policy.

The following deficiencies were observed (see LIC 809D) 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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2023 01:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
87465(c)(2)

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87465 (c )(2) Incidental Medical & Dental Care 87465(c)(2) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
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LPA was provided Signed documentation of Policy and procedure review with Staff (S1) as well as In-Service training of Medication error protocol, Documentation Standards for Medication Policy, & Controlled Substance Medication protocol. POC cleared at time of visit.
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Based on self-report submitted by facility, a staff, provided another resident’s PRN pain medication to a resident, not administering PRN medication to R1 as prescribed by their Physician which is an immediate Health and Safety risk to the resident(s) in care.
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POC cleared at time of visit.

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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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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