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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803994
Report Date: 04/24/2025
Date Signed: 04/24/2025 05:22:42 PM

Document Has Been Signed on 04/24/2025 05:22 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: 121DATE:
04/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Bill Phelps, Interim AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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License Program Analyst (LPA) Shannan Hansen arrived at facility to conduct an unannounced annual inspection and was greeted by Bill Phelps, Interim Administrator. Facility is 2 stories with 84 AL apartments & 2 memory care units totaling 34 apartments. Fire clearance has been approved for 150 non-ambulatory residents, of which 35 may be bedridden, by the County Fire Department. There is currently a total of 121 residents, of which 33 are living in memory care, and 13 residents under Hospice care.

Facility tour/inspection began at 9:00 AM:

LPA toured the community with Interim Administrator. The tour of the facility included 15 resident apartments, activity rooms, Library, Salon, dining rooms, kitchen and outdoor patios. All interior parts of the facility were found to be a comfortable temperature measuring between 75 to 78 degrees F. Exits and pathways were free from obstructions. The assisted living residents also have an outdoor patio courtyard. Delayed egress doors from the memory care units (Lee’s Lane & Hogan’s Court) have audible alarms when doors are opened without access codes. Hot water temperature in 15 total rooms of AL & MC measured between 112.8 degrees F to 132 degrees F. with 14 rooms not within regulation of 105 to 120 degrees F. Temperature immediately turned down and per Administrator, plumber was contacted to assess issue following day (see LIC 809D) Resident bathrooms had required slip resistant mats and grab bars. While touring facility at approximately 9:36 AM to 11:00 AM LPA and Interim Administrator observed 4 storage closets ( in MC & AL) unlocked containing multiple gallons of paint, toxic chemicals, cement, cleaning products (see pic & LIC 809-D), staff locked doors. LPA observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for residents in care. Food was found to be handled and stored in a safe manner. Dining rooms and kitchen were inspected and maintained per regulation. Menus with snack and beverages are available to residents. Activity schedules are posted. Facility has a theater and multiple indoor and outdoor sitting areas and a private dining area.



Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/24/2025
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Continued from LIC809: Fire extinguishers were last serviced 1/8/2025. Fire safety system including smoke detectors and carbon monoxide detectors and sprinklers were last tested by Central Marin Fire Dept. on 11/13/2023 having a 5 year check next due 2026. Fire department conducted Kitchen inspection 2/2/2025 which fully passed along with the elevator. Disaster drills are conducted quarterly with the last being 3/7/2025. Facility has a permanently installed generator to power entire facility should there be a power outage.

At approximately 12:30 AM, LPA reviewed 10 resident records and found 10 of 10 residents have current physician's reports and updated care plans. 10 of 10 records contained current and signed admission agreements and medication records are thorough and contained physician's orders for each resident. LPA reviewed centrally stored medication record and found to be in compliance.



At approximately 1:45 PM, LPA reviewed 10 staff records. All records contained documentation of completed training as required. Evidence of current first aid and CPR training were present for required staff. All staff had required criminal record clearance and were associated.

Rabah Sbaitan Administrator Certificate 6071494740 expires 7/24/2026. LPA observed Interim Administrator William Phelps Administrator Certificate pending. All fees are current. CCL had not received any incident reports since 3/3/2025 & inquired. LPA was presented with 6 Incident Reports, one a Death Report that occurred from 3/9/2025 to 4/18/2025 that are to be submitted within seven (7) days. Interim Administrator advised staff to send by fax manually as there must be a problem with the machine (see LIC809-D).
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..


LPA Hansen is requesting Licensee to update and submit the following documents by 5/9/2025 to SRRO:

LIC 308 Designation of Facility Responsibility

LIC 610 Emergency Disaster Plan (if changes)

Copy of current Lease

Copy of Administrator Certificate

Proof of Liability Insurance

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/24/2025 05:22 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/24/2025 at 03:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA & Interim Admin's observation & interview during annual inspection, the licensee did not comply with the section cited above in 14 out of 15 faucets used by resident in care measured between 120.2 degrees F & 132 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
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Interim Administrator to submit a LIC 9098 self certification that hot water temperature has been adjusted with receipt from Plumer by POC date of 04/25/25 Additionally, Licensee to submit 14 day log of water temperature to ensure temperature is within regulation and submit to CCL by 05/09/25
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA & Interim Administrators observations during Annual Inspection, the licensee did not comply with the section cited above in finding 4 storage closets ( in MC & AL) unlocked containing multiple gallons of pain, toxic chemicals, cement, cleaning products, etc.. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
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Administration shall provide refresher training for all staff on the requirements of 87309 and will provide proof of completion to CCL by POC date in order to clear the deficiency. (With topic, instructor & dated sign in log by employees).
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2025 05:22 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/24/2025 at 03:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)(D)
87211(a)(1)(D):Reporting Requirements:(a) Each licensee shall furnish to the licensing agency...(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident..

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not submitting 6 Required Incident Reports to CCL, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2025
Plan of Correction
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Licensee to provide training to staff who submit Reports to CCL and conduct practice test by 4/25/2025 to clear citation as Facility believes there is a falty fax issue.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
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