216803994-5-9-2024-21-AS-BMOS-D58PTU-20240513113632

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803994
Report Date: 05/09/2024
Date Signed: 05/09/2024 09:20:20 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
04/22/2024 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20240422101726

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: 96	DATE:	05/09/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Rabah Sbaitan, General Manager		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff did not ensure medication was dispensed as prescribed

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.

Staff did not ensure medication was dispensed as prescribed – Complainant alleges resident (R1)’s nebulizer was broken making staff unable to provide liquid albuterol treatment and when the resident was questioned, they stated they didn’t remember because it had been so long.

Per review of Medication Administration Records (MAR) and interviews conducted indicated, resident was given nebulizer treatment as prescribed. Per interview with staff (S1) they experienced functional issues with the nebulizer but determined this nebulizer functioned differently than others they had used. S1 was able to figure out how nebulizer worked and provided treatment per doctors’ orders. No further issues noted.
Continue on LIC9099-C

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: 05/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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-20240422101726

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: 05/09/2024

NARRATIVE

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R1 was admitted on 4/17/2024, responsible party provided nebulizer to facility on 4/18/2024, which was reported to be functioning. On 4/19/2024 LPA was informed issues with device and doctor contacted and provided order for new machine. Per interview with staff at another licensed facility where resident now resides, S2 initially believed the device was not functioning properly until a medication technician was able to get it to operate. Based on LPAs interviews with staff, complainant, and documents obtained, LPA was unable to either prove or disprove staff did not ensure medication was dispensed as prescribed. 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: 05/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC9099 (FAS) - (06/04)

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