216803994-2-12-2024-21-AS-BMOS-D2FQAJ-20240214110000

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803994
Report Date: 02/12/2024
Date Signed: 02/12/2024 10:33:23 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
12/08/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20231208162004

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:	09:30 AM
MET WITH:	Rabah Sbaitan, General Manager		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility did not report incident to responsible party timely

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 did not report incident to responsible party timely – Complainant alleges resident (R1) fell the morning of 12/6/2023 and the facility did not contact R1’s family for over 24 hrs regarding the incident.

LPA’s interview with staff (S1) revealed once they were informed by staff, S1 called R1’s responsible party. (LPA observed personal cell phone of wellness nurse showing 1 call made to responsible party on 12/6/23). S1 also indicated they could not leave a message as the phone stated, "voice mail was full and could not accept message". Emergency Medical Services (EMS) report obtained revealed 911 was called at 11:14am on 12/6/2023 and paramedics arrived shorty after.
Continue on LIC9099C

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-20231208162004

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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Paramedics found R1 sitting in a chair with care staff. R1 denied falling or hip pain. EMS assessment revealed hips and pelvis feel intact and firm, no obvious signs of broken bones or dislocation and R1 able to bare weight with walker. R1 denied any other pain. R1 advised an ambulance was on scene and transport could be conducted to ER. R1 understood this but did not want ambulance transport but wanted to take pain meds and rest at facility. Attempts to contact R1’s daughter via phone were unsuccessful. Facility care notes revealed on the following day (12/7/2023) at approximately 11:10am private 1:1 reported to nurse R1 was experiencing pain in left hip, nurse assessed and agreed at which point, 1:1 contacted family with nurse present and decided to call 911 again, sending R1 to hospital. Self reported incident submitted to community care licensing on 12/13/2023 revealed R1 diagnosed with closed dislocation of left hip and returned to facility same day. Former Administrator indicated, the facility Plan of Operations (POO's) does not state any specific time frame at which staff needs to contact the family etc. of an incident other than as soon as possible and within Regulations.

Based on LPAs interviews with staff, complainant, and documents obtained, LPA was unable to either prove or disprove facility did not report incident to responsible party timely. 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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