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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803994
Report Date: 11/06/2024
Date Signed: 11/06/2024 02:17:40 PM

Document Has Been Signed on 11/06/2024 02:17 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/
DIRECTOR:		ABUSBAITAN,RABAHFACILITY TYPE:
740
ADDRESS:5555 PARADISE DRIVETELEPHONE:
(415) 483-1399
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY: 150CENSUS: 93DATE:
11/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Rabah Abusbaitan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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On November 6, 2024, Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management visit in response to a self-reported incident report and met with Rabah Abusbaitan, Administrator.

On October 30, 2024 the Santa Rosa Regional Office received a self-reported incident report reporting resident (R1) in memory care made statements that R1 was raped. LPA requested documentation. LPA verified that local police department, responsible party and Ombudsman were notified. Administrator stated that an exam by doctor was declined by responsible party.

No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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