216803994-2-12-2024-21-AS-BMOS-D2FQED-20240214110609

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803994
Report Date: 02/12/2024
Date Signed: 02/12/2024 10:28:54 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
11/14/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20231114084622

FACILITY NAME:	AEGIS LIVING CORTE MADERA		FACILITY NUMBER:	216803994
ADMINISTRATOR:	NITHI NARASAPPA		FACILITY TYPE:	740
ADDRESS:	5555 PARADISE DRIVE		TELEPHONE:	(415) 483-1399
CITY:	CORTE MADERA	STATE: CA	ZIP CODE:	94925
CAPACITY:	150	CENSUS: 85	DATE:	02/12/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Rabah Sbaitan, General Manager		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Facility staff did not safeguard resident’s personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation and met with Rabah Sbaitan, General Manager.

Facility staff did not safeguard resident’s personal belongings – Complainant alleges resident (R1)’s gold necklace with pendant went missing after hospital visit 6/2022 and reported to general manager, then in 9/2023 R1’s watch went missing.

R1s’ Personal Property Inventory documents obtained from move in singed and dated by POA 6/13/2014 indicates “Items to be inventoried will be listed on form LIC 621, signed, and dated by all parties. A copy of the inventories will be provided to all parties. If no inventory is desired, the resident or responsible party will write “waived” on the LIC 621 form, and sign & date it. Waived has been written on form. Continue 9099C

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20231114084622

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: 02/12/2024

NARRATIVE

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Staff informed If items go missing or are brought to the facilities attention our procedure is, we have a missing register log and we report it to the general manager, who reports it to the family, and if the item is more than $100.00 we do a police report. Facilities theft & loss log obtained 11/22/2023 from 1/2020 through 11/11/2023 lists 28 missing items 18 found. No items for R1 on list. Interview with former Administrator indicated one gold necklace was reported via email from reporting party but was not aware of any other items missing. Interviews with 5 out of 7 staff revealed no information of missing items or that they were reported to them. Police report regarding missing items was obtained and indicates case closed.

Based on LPAs record review of facility as well as outside documents, and interviews with staff, LPA was unable to either prove or disprove facility staff did not safeguard resident’s personal belongings. Therefore, the allegation is Unsubstantiated.

Although the allegation 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 allegation is Unsubstantiated.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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