<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803994
Report Date: 04/03/2024
Date Signed: 04/03/2024 03:03:55 PM


Document Has Been Signed on 04/03/2024 03:03 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: 102DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Rabah Abusbaitan, General ManagerTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
License Program Analyst's (LPA’s) Shannan Hansen arrived at 8:15 AM to conduct an unannounced annual inspection and was greeted by Rabah Abusbaitan, General Manager. There is a total of 102 residents, of which 23 dementia residents, and 13 residents under Hospice care.

Facility tour/inspection began at 8:45 AM:

LPA toured the community with General Manager and Maintenance Director Jose Herrera. The tour of the facility included nine 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. Memory care courtyard was observed to have broken glass on ground (see pic & LIC809-D) glass was immediately removed by maintenance director. Hot water temperature measured within regulation of 105 to 120 degrees F in eight of nine rooms tested; although one memory care room did not have hot water only reaching 67 degrees F observed by LPA & General Manager at approximately 9:30 AM (see LIC 809-D), as well bathroom window was open and did not contain required screen (see pic LIC 809-D). Bathrooms contained necessary grab bars and showers contained non-slip floor/mats. While touring memory care kitchenette at approximately 9:36 AM LPA and General Manager observed a bottle of Clorox toilet bowl cleaner in unlocked cabinet (see pic & LIC 809-D), staff removed. 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
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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 5


Document Has Been Signed on 04/03/2024 03:03 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: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs & General Manager's observation, the licensee did not comply with the section cited above when touring memory care courtyard observed large shards of broken glass on the ground by walkway accessible to residents in memory care, which poses an immediate health, safety or personal rights risk to persons in care. Maintance remived immediately.
POC Due Date: 04/04/2024
Plan of Correction
1
2
3
4
Licensee to submit 1) Self-Certification stating that training will be conducted with facility staff, 2) an In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(1). Self Certification to be submitted to Community Care Licensing (CCL) by POC due date of 4/4/2024, and Training to be submitted by due date of 4/12/2024.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs and General Managers observation, the licensee did not comply with the section cited above when touring memory care kitchenette finding Clorox toilet cleaning in unlocked cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
1
2
3
4
Licensee to submit 1) Self-Certification stating that training will be conducted with facility staff, 2) an In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(2). Self Certification to be submitted to Community Care Licensing (CCL) by POC due date of 4/4/2024, and Training to be submitted by due date of 4/12/2024.
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: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 04/03/2024 03:03 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: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's interview & record review, the licensee did not comply with the section cited above in 1 out of 5 staff did not obtain Health Screening test & TB test results which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
1
2
3
4
Licensee to have all staff obtain a health screening with TB test and submit copies to Community Care Licensing for review by POC due date 4/17/2024. Licensee to notify CCL if more time is needed.

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: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


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: 04/03/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809

Fire extinguishers were last serviced 1/9/2024. Fire safety system including smoke detectors and carbon monoxide detectors and sprinklers were last tested by Central Marin Fire Dept. on 11/13/2023. LPA observed multiple smoke detectors and carbon monoxide detectors functioning. Disaster drills are conducted quarterly with the last being 3/26/2024. Facility has a permanently installed generator to power entire facility should there be a power outage.



At approximately 10:45 AM, LPA reviewed 5 resident records and found 5 of 5 residents have current physician's reports and care plans. 5 of 5 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 12:30 PM, LPA reviewed 5 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. Staff (S1)’s records did not contain required health screening or TB results (see LIC 809-D).

LPA Hansen is requesting Licensee to update and submit the following documents by 4/22/2024 to SRRO:

LIC 308 Designation of Facility Responsibility

LIC 500 Personnel Record

LIC 610 Emergency Disaster Plan (if changes)

Copy of Administrator Certificate

Proof of Liability Insurance

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: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 04/03/2024 03:03 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: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and General Manager's observation, the licensee did not comply with the section cited above in that a memory care residents bathroom window (that was open without a censor) did not contain required window screen, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
1
2
3
4
Facility replaced screen during LPA inspection. Deficiency cleared.
Type B
Section Cited
CCR
87303(e)(2)

87303(e)(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 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs and Licensee observation, the licensee did not comply with the section cited above in one memory care residents faucet was only 67 degrees F , which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
1
2
3
4
Licensee will to submit as proof of correction a 2 week measurement log of water temperature readings, taken once in the morning and once at night, showing temperatures in compliance with regulation 87303(e)(2).
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: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5