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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803994
Report Date: 02/12/2024
Date Signed: 02/12/2024 01:59:46 PM


Document Has Been Signed on 02/12/2024 01:59 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:DONALD STAMETSFACILITY TYPE:
740
ADDRESS:5555 PARADISE DRIVETELEPHONE:
(415) 483-1399
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY:150CENSUS: 85DATE:
02/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rabah Sbaitan, General ManagerTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection, while delivering complaint findings, and met with General Manager Rabah Sbaitan. The purpose of this case management is to follow up on five self reported incident reports submitted to Community Care Licensing (CCL). Two on 12/22/2023 and one on 12/28/2023, 1/29/2024, 2/1/2024, & 2/8/2024.

CCL received a self reported incident report reporting on 12/14/2023 night medication technician (Med-tech) notified nurse resident (R1) had frequent urination. Review of R1’s medication records revealed R1 had not received Tamsulosin medication since 11/26/2023 due to pharmacy unable to renew prescription as incorrect doctor was listed. Primary Care Physician’s (PCP) office notified, and emergency supplies of medication were delivered and given to R1 on 12/15/2023.

LPA obtained additional information regarding a medication error that occurred on 12/14/2023 involving R2. On 12/13/23 delivery of Midodrine was assigned to Med Tech instead of nurse, which was given at 8 am, then another dose was given at 9:40am by nurse without checking Emar. R2 assessed with no adverse effects noted. All required parties notified. In-service training provided & LPA obtained copy.

LPA followed up on an incident submitted to CCL on 1/16/2024 for a medication error that occurred on 12/28/2023. On 12/29/2023 AM Medication manager found cup with R3’s PM medications. Nurse assessed R3 with no adverse effects. LPA obtained internal investigation, disciplinary action, & In-service training. LPA is providing LIC 9102 TA for reporting incident to CCL later then Title 22 regulations of 7 days.

CCL received a self reported incident report on 1/29/2024 of a medication error that occurred on 1/17/2024. R3 had received two 5mg tablets of their amlodipine instead of one as staff opened a new bubble pack of mediation prior to finishing the current supply. There were no adverse effects shown and all required parties notified. Continue on LIC809-C

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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
VISIT DATE: 02/12/2024
NARRATIVE
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 LPA obtained internal investigation, disciplinary action, & in-service training.

On 2/8/2024 CCL received a self reported incident report regarding R4. On 1/29/2024 staff provided R4 2 doses of Levetiracetam 250mg at 9am instead of 1. R4’s Mediation records indicate 1 dose in AM & double the dose at 5pm, daily. It was revealed a new bubble pack was opened when the old one was not empty. R4 did not show any adverse effects. All required parties notified. LPA obtained staff records & in-service training. LPA is issuing a citation today for multiple medication errors and Civil Penalties for repeat violation in less then 12 months.

CCL received a self reported incident report reporting on 1/30/2024 at approximately 5:40 pm R5 eloped from community. Staff and law enforcement conducted search. At approximately 6:15 pm R5 was escorted back to community by neighbors of area. Full assessment conducted of R5 with no signs of injury or pain noted. LPA obtained records indicating R5 has diagnosis of dementia and is not to leave community unassisted. LPA is issuing a citation today for R5 eloping from facility without staff knowledge on 1/30/2024. General Manager has informed R5 just moved into facility end of January 2024. Wonder guard alarm had been placed on R5 and 1:1 had been implemented but after care meeting on 2/6/2024 R5 was moved to memory care unit.

Citation issued during visit. ****Civil Penalties are being assessed in the amount of $250 due to a second repeat citation issued for the same section 87705(b)(2) Care of Persons with Dementia, in less than 12 months. Deficiency last cited on 4/11/2023.

Citation issued during visit. ****Civil Penalties are being assessed in the amount of $250 due to a second repeat citation issued for the same section 87465(a)(5) Incidental Medical and Dental Care Services. in less than 12 months. Deficiency last cited on 6/15/2023.

*******Total Civil Penalties being given today $500

Appeal of Rights Given.



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: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/12/2024 01:59 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: 02/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2024
Section Cited
CCR
87465(a)(5)

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87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed.
This requirement is not met as evidenced by:
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LPA obtained log of in-service trainings with signatures regarding medication handling & investigations.
HSD has informed Med Techs on duty have been provided numbers to contact if unable to complete med pass.
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Based on record review and interview with GM & HSD, the facility did not ensure R1-R4 medications were given as prescribed by doctor on 4 different incidents which poses an immediate health and safety risk to resident in care.
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POC has been cleared at today's visit.

Civil Penalties for $250 for repeat violation of same deficiency in less then 12 months.
Type A
02/13/2024
Section Cited
CCR87705(b)(2)

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87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by
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Facility conducted care confrence with family and moved R5 to memory care unity within the week of incident.
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Based on a record review & interview with GM it was found that resident (R5) had been reported by facility to be missing from facility care. Medical documents indicate diagnosis of dementia.
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POC has been cleared at today's visit.

Civil Penalties for $250 for repeat violation of same deficiency in less then 12 months.
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: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
LIC809 (FAS) - (06/04)
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