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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803994
Report Date: 03/10/2026
Date Signed: 03/10/2026 02:02:12 PM

Document Has Been Signed on 03/10/2026 02:02 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AEGIS LIVING CORTE MADERAFACILITY NUMBER:
216803994
ADMINISTRATOR/
DIRECTOR:		PASCUAL, EUGENEFACILITY TYPE:
740
ADDRESS:5555 PARADISE DRIVETELEPHONE:
(415) 927-4200
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY: 150CENSUS: 98DATE:
03/10/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Eugene Pascual, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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At approximately 11:10 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Case Management visit and met with Administrator, Eugene Pascual and Health Services Director, Tosha Chowdory. Today's visit was in regards to two (2) Incident Reports (IRs) for Resident 1 (R1) and for Resident 2 (R2) submitted to Community Care Licensing (CCL) by the facility.

The IR for resident R1 states that on 2/25/2026, while being transferred by one (1) staff member (S1) resident R1 fell. Facility Progress Notes for resident R1 indicate that they did not directly fall, but instead was lowered to the ground by staff member S1. Paramedics were called and resident R1 was taken to a local hospital. Resident R1 did not suffer any fractures as a result of this incident. Resident R1's Individualized Service Plan states that two (2) staff members are needed to assist transferring resident R1. As the facility did not follow residents R1's Individualized Service Plan, the facility will be cited for this deficiency. During today's visit, LPA was informed that staff members carry phones that show in the individual care needs of each resident to whom they are assigned. On 2/26/2026 the facility conducted Care Plan training to reiterate to staff members that they need to review residents care needs and to follow the Individualized Service Plans of residents. As a result of this incident, staff member S1's employment with the facility was terminated. As the facility has already conducted Care Plan training, the deficiency will be cleared during today's visit.

The IR for Resident R2 states that on 2/17/2026, resident R2 was mistakenly given the wrong medications. At 7:00 AM, staff member S2 was preparing medications for the morning medication pass. They put medications for a third (3) resident (R3) in a cup for dispensing. Staff member S2 then realized that resident R3 had left the facility for a doctors appointment. Staff member S2 contacted the family member escorting resident R3 to their doctors appointment. The family member asked that the medications be held until resident R3 returned to the facility. Continued on 809-C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/10/2026 02:02 PM - It Cannot Be Edited


Created By: Robert Frank On 03/10/2026 at 12:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2026
Section Cited
CCR
87468.2(a)(4)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights...: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are...to meet their needs. This requirement is not met as evidenced by:
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Licensee or Administrator to conduct Care Plan training for staff members to reiterate that residents' Individualized Service Plans be followed and to submit proof of training to Community Care Licensing by POC due date of 3/11/2026.
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Based on interview & record review, the licensee did not comply with the section cited above in that R1's Individualized Service Plan was not followed when R1 was transferred by only one (1) staff member which poses a potential health, safety or personal rights risk to persons in care.
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2026


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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AEGIS LIVING CORTE MADERA
FACILITY NUMBER: 216803994
VISIT DATE: 03/10/2026
NARRATIVE
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...Continued from 809
At approximately 2:00 PM, resident R2 requested their normal afternoon medications. Staff member S2 then proceeded to add resident R2's medications to cup that contained resident R3's missed morning medications. As a result of this error, resident R2 mistakenly took medications intended for resident R3. The facility immediately had resident R2 assessed by a Registered Nurse and placed resident R2 on alert charting with hourly checks of vital signs. R2's emergency contacts were notified. Additionally, the facility's Medical Director (a licensed Medical Doctor) was on site and they also monitored R2's condition. Resident R2 was kept on alert charting for 72 hours. Resident R2 suffered no adverse effects of the medication error. The facility will be cited for this medication error. The facility took disciplinary action against staff member S2. Staff member S2 also underwent four (4) days of retraining and shadowing the lead Medical Technician (Med Tech). Additionally, all the facility's Med Techs underwent Medication Policy training. As this disciplinary step and retraining was already completed, the deficiency will be cleared during today's visit.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809Ds, Plan of Corrections, 811 Confidential Names, Appeal Rights and Letters of Deficiency Citations Cleared discussed and provided to Administrator Pascual. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/10/2026 02:02 PM - It Cannot Be Edited


Created By: Robert Frank On 03/10/2026 at 01:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2026
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical... shall be developed...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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Licensee or Administrator to conduct Medication Policy training for the facility's Medical Technicians and submit proof of training to Community Care Licensing by POC due dater of 3/11/2026.
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Based on interview & record review, the licensee did not comply with the section cited above in that medications for resident R3 were given to resident R2, which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2026


LIC809 (FAS) - (06/04)
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