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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803994
Report Date: 09/26/2024
Date Signed: 09/26/2024 01:52:35 PM


Document Has Been Signed on 09/26/2024 01:52 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:ABUSBAITAN,RABAHFACILITY TYPE:
740
ADDRESS:5555 PARADISE DRIVETELEPHONE:
(415) 483-1399
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY:150CENSUS: 105DATE:
09/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Rabah Abusbaitan, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced at facility to conduct a case management and met with Tosha Chowdory, Health Services Director & Rabah Abusbaitan, Administrator. The purpose of this case management inspection is to follow up on a self-reported incident report submitted to Community Care Licensing (CCL).

On 9/24/2024 CCL received an incident report form reporting on 9/19/2024 at approximately 7:30pm resident in the assisted living observed resident (R1) had eloped from community. At approximately 8:00 PM facility received a call R1 was located next door at grocery store, approximately 30 minutes later. Investigation revealed R1 left through side gate of facility memory care unit after landscaping company left gate open. R1 assessed at return to facility no injuries and vitals noted. LPA obtained records indicating R1 has diagnosis of dementia and is not to leave facility unassisted and exit seeks.

Appeal Rights Given

The following deficiencies were observed (see LIC 9099D) 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: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
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 09/26/2024 01:52 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: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2024
Section Cited
CCR
87705(b)(2)

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87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by**
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Facility provided Elopement in-service training conducted, for regulation 87705 Care of Persons with Dementia with staff. In addition, a plan of how residents in Memory Care will be kept safe from wandering when landscaping company cuts grass.
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Based on record review it was found that resident (R1) had been reported by facility to be missing from facility care. R1 is diagnosed with dementia and based upon Physicians Report, requires special supervision for confusion and wander risk. This is an immediate health & safety risk to resident in care.
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LPA Obtained copy of trainings w signatures and dates. Including, new plan for days when gardeners come.

Citation cleared at visit....

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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: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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