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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
216803994
Report Date:
07/21/2022
Date Signed:
07/21/2022 12:17:57 PM
Document Has Been Signed on
07/21/2022 12:17 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:
STAMETS, DONALD
FACILITY TYPE:
740
ADDRESS:
5555 PARADISE DRIVE
TELEPHONE:
(415) 483-1399
CITY:
CORTE MADERA
STATE:
CA
ZIP CODE:
94925
CAPACITY:
150
CENSUS:
111
DATE:
07/21/2022
TYPE OF VISIT:
Post Licensing
UNANNOUNCED
TIME BEGAN:
10:35 AM
MET WITH:
Donald Stamets - Administrator
TIME COMPLETED:
12:18 PM
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Post-Licensing Inspection and met with Administrator Donald Stamets. LPA was greeted by staff and asked to screen for COVID. Proof of vaccination was requested. Facility is 2 stories and contains both assisted living and memory care with a current census of 111.
LPA toured building and grounds which were clean and in good repair. Staff were observed wearing masks. All staff are vaccinated except 1 medical exemption and boosted if eligible. 98% of residents are vaccinated and boosted if eligible with a clinic scheduled to get all residents vaccinated by 7/31/2022. Facility currently conducts surveillance testing every Friday. LPA and administrator discussed infection control plan which has been submitted.
Medications are centrally stored and locked making them inaccessible to residents. Toxins are secured and inaccessible to residents. Fire extinguishers were last inspected in January of 2022. LPA observed fire alarm/sprinkler system throughout the facility. Facility has the necessary personal protective equipment (PPE) to support a resident in isolation. All bedrooms are private therefore residents could isolate in their own bedrooms if necessary. Resident bathrooms contain necessary grab bars and non-slip floors/mats.
LPA and administrator discussed Guardian and association process.
No deficiencies observed during today's inspection.
Exit interview conducted with Administrator.
SUPERVISOR'S NAME:
Bethany Moellers
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR NAME:
Shannan Hansen
TELEPHONE:
707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
07/21/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/21/2022
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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