216803994-4-3-2024-21-AS-SHAN-D3YU7Q-20240403152019

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803994
Report Date: 04/03/2024
Date Signed: 04/03/2024 03:20:25 PM

Document Has Been Signed on 04/03/2024 03:20 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 MADERA		FACILITY NUMBER:	216803994
ADMINISTRATOR:	DONALD STAMETS		FACILITY TYPE:	740
ADDRESS:	5555 PARADISE DRIVE		TELEPHONE:	(415) 483-1399
CITY:	CORTE MADERA	STATE: CA	ZIP CODE:	94925
CAPACITY:	150	CENSUS: 102	DATE:	04/03/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Rabah Sbaitan, General Manager		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA), Shannan Hansen conducted an unannounced Case Management inspection of the facility for the purpose of following up on an Order of Immediate Exclusion letter issued on February 8, 2024. Also to follow up on three self reported incident reports submitted to Community Care Licensing (CCL). LPA met with Rabah Sbaitan, General Manager.

During the Case Management inspection, General Manager Rabah Sbaitan confirmed Excluded Staff Member is no longer working in the facility or residing in the facility. LPA obtained a copy of the Resident Roster, LIC 500 and the staff schedule. In addition, LPA and General Manager toured the facility. Excluded Staff Member was not seen on the premises. Based on evidence obtained during today’s Case Management Inspection, the LPA has verified Excluded Staff Member is not present, employed, or residing at the facility. Verification of removal is complete.

LPA also followed up on 2 medication errors that were self-reported to community care licensing on 3/6/2024 & 3/11/2024.

On 3/1/2024 it was noted by staff (S1) Resident (R1) had been given a double dosage of medication on 2/27/2024 new bubble pack opened 2/28/2024 given out of a second bubble pack. No adverse effected noted and all required parties notified. Conversation with Health Services Director (HSD) indicated facility has made changes to medication entering policies to prevent future medication errors.

LPA obtained additional information regarding a medication error that occurred on 3/1/2024 when staff observing R2 holding medications in mouth noticed previous days 6 medications in medicine cup, to have been taken later on the previous day. No adverse effects observed, all required parties notified. LPA obtained in service training's, disciplinary actions for staff & investigations.

Continue on LIC809-C

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

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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: 04/03/2024

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On 6/15/2023 LPA conducted a case management and cited facility for medication errors following regulation 87465(a)(5) and again on 2/12/2024 LPA conducted a case management of facility and cited for multiple self-reported medication errors and assessed civil penalties to facility for repeat violations in less then 12 months for same regulation.

LPA is issuing a citation today for medication errors and Civil Penalties for a 3^rd repeat violation in less then 12 months.

Citation issued during visit. ****Civil Penalties are being assessed in the amount of $250 due to a second repeat citation issued for the same section 87465(a)(5) Incidental Medical and Dental Care Services. in less than 12 months. Deficiency last cited on 2/12/2024 & 6/15/2023.

*******Total Civil Penalties being given today $250.00

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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 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)

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Document Has Been Signed on 04/03/2024 03:20 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

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/04/2024 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by	1 2 3 4 5 6 7	LPA obtained log of in-service trainings with signatures regarding medication handling & investigations.
	8 9 10 11 12 13 14	Based on record review and interview with GM & HSD, the facility did not ensure R1-R2 medications were given as prescribed by doctor on 2 different incidents which poses an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14	POC has been cleared at today's visit. Civil Penalties for $250 for repeat violation of same deficiency in less then 12 months.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 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)

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