<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803994
Report Date: 11/14/2023
Date Signed: 11/28/2023 10:07:59 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
09/14/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20230914082504
FACILITY NAME:AEGIS LIVING CORTE MADERAFACILITY NUMBER:
216803994
ADMINISTRATOR:STAMETS, DONALDFACILITY TYPE:
740
ADDRESS:5555 PARADISE DRIVETELEPHONE:
(415) 483-1399
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY:150CENSUS: 106DATE:
11/14/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Nithi NarasappaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect resulted in resident developing sepsis


***** This is an amended version of the original report******
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. It has been alleged that staff neglect resulted in R1's sepsis condition. This investigation indicates that resident ( R1) was hospitalized on 9/12/23 for symptoms of rhinovirus infection; R1 was discharged on 9/16/23 with diagnosis that included Sepsis; R1 reported upon admission to be feeling in R1's "general state of health until earlier the same day;" Staff physician observed R1 mid-day 9/12/23 and reports" ( R1) did not have any respiratory distress evident;" Private caregiver for R1 who provides care twice a week has stated that caregiver has no knowledge of any neglect of R1 by staff; Facility caregivers who showered and assisted R1 the morning of 9/12/23 report not observing R1 exhibiting any unusual symptoms that would require intervention. This investigation included review of documents, including medical records for R1, as well as interviews with staff; relatives, and witnesses. Although the allegation may be true, based upon the documents and statements, there is not a preponderance of evidence to prove the allegation true or false. Therefore, the allegation is UNSUBSTANTIATED.
Report left.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
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
09/14/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20230914082504

FACILITY NAME:AEGIS LIVING CORTE MADERAFACILITY NUMBER:
216803994
ADMINISTRATOR:STAMETS, DONALDFACILITY TYPE:
740
ADDRESS:5555 PARADISE DRIVETELEPHONE:
(415) 483-1399
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY:150CENSUS: 106DATE:
11/14/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Nithi NarasappaTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not administer resident's medication as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. It has been alleged that R1 was not administered a PRN medication for respiratory symptoms on 9/12/23 as ordered by a physician. This investigation indicates that R1 was seen by facility physician at approximately 11:30 am on 9/12/23 when R1 requested cough medicine; Physician determined nebulizer to be more appropriate and directed staff to administer the medication; R1’s Medication Administration Record for September 12, 2023 indicates that neither the AM dose or the PRN dose ordered by physician at approximately 11:30 am were administrated to R1; R1’s relative reports being told by R1 that the PRN medication ordered by physician on 9/12/23 was not administered to R1. Based upon the statements and documents reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. 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. ***Continued next page***

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20230914082504
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: 11/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Exit interview conducted and appeal of rights provided. $250.00 Civil Penalty issued for repeat violation with 12 months.

Report left.



****This is an amended version of the original report*****
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20230914082504
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: 11/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2023
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
87465(a)(4) Incidental Medical and Dental Care… The plan shall… provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medications as needed. *** Based on statements and documents,
1
2
3
4
5
6
7
Administration will provide refresher training in medication administration for all staff who administer medications. Training to include addressing issues identified by this complaint. Proof of training to be submitted to CCL by POC date in order to clear the deficiency.
8
9
10
11
12
13
14
this requirement not met as evidenced by: PRN medication ordered by physician for R1 was not administered on 9/12/23. This posed an immediate risk to R1’s health. $250.00 Civil Penalty issued for repeat violation within 12 months.
8
9
10
11
12
13
14

***This is an amended version of the
original report******
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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4