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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803994
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:51:58 PM


Document Has Been Signed on 04/25/2024 01:51 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: 101DATE:
04/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH: Rabah Sbaitan, General Manager & Divinder Singh, Health Services DirectorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Shannan Hansen was at facility opening a complaint and conducted a Case Management for the purpose of following up on a self reported incident report submitted to Community Care Licensing (CCL). LPA met with Rabah Sbaitan, General Manager & Divinder Singh, Health Services Director.

On 4/22/2024 CCL received a self reported incident report indicating on 4/18/2024 facility conducted a medication review and it was revealed that on 4/9/2024 resident (R1) received 1 tablet of Clonazepam (1mg) instead of the prescribed 2 tablets. No adverse effects observed, all required parties notified. LPA obtained, investigation and disciplinary actions for staff.

On 6/15/2023 LPA conducted a case management and cited facility for medication errors following regulation 87465(a)(5) and on 4/3/2024 LPA conducted a case management of facility and cited for two self-reported medication errors and assessed civil penalties to facility for repeat violations in less than 12 months for same regulation.

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

Citation issued during visit. ****Civil Penalties are being assessed in the amount of $1000 due to a third 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 6/15/2023 & 4/3/2024.

*******Total Civil Penalties being given today $1,000.00

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: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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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Document Has Been Signed on 04/25/2024 01:51 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: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2024
Section Cited
CCR
87465(a)(5)

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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:
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LPA obtained investigation along with disciplinary action. LPA is requesting facility to provide name of training company by POC due date of 4/26/2024 & for LPA facility to conduct Internal medication training from person outside of organization to all staff providing ......
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Based on record review and interview with GM & HSD, the facility did not ensure R1 medications were given as prescribed by doctor which poses an immediate health and safety risk to resident in care.
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medication on all shifts and submit log in sheet with written staff names & signatures w/ date and signed by trainer by POC due date 5/9/2024 to clear POC.
Civil Penalties for $1000 for 3rd repeat violation of same deficiency in less than 12 months.

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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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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