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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803994
Report Date: 08/16/2022
Date Signed: 08/16/2022 12:13:57 PM


Document Has Been Signed on 08/16/2022 12:13 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:STAMETS, DONALDFACILITY TYPE:
740
ADDRESS:5555 PARADISE DRIVETELEPHONE:
(415) 483-1399
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY:150CENSUS: 113DATE:
08/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Donald Stamets, AdministratorTIME COMPLETED:
11:31 AM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection and met with Donald Stamets, Administrator. The purpose of this case management is to follow up on two self reported incidents reports submitted to Community Care Licensing (CCL) on 7/14/2022.

CCL received a self reported incident report reporting on 7/5/2022 at 1:00 PM, nurse was summoned to resident’s (R1) room to assess for frequent coughing episodes with clear phlegm since lunch. Tested negative for COVID. While assessing resident nurse and care manager helped R1 to the restroom, while seated on toilet R1 suddenly slumped forward and was unresponsive. R1 was taken to Marin General Hospital (MGH) ER for evaluation and discharged same day with no new orders. Discharge diagnosis syncope.

CCL received a second incident report on 7/14/2022 of an incident that occurred on 7/7/2022 at approximately 9:00 PM with the same resident (R1). Medication Care Manager (MCM) noticed resident having slurred speech, vitals taken BP 191/86, R1 was taken to MGH ER for evaluation and admitted for further tests. R1 returned 7/10/2022 with new medication orders and follow up with Dr. on 7/12/2022. Administrator and Wellness Nurse Singh advised LPA after R1 had medication adjusted there was no reoccurring issues with syncope and R1 has remained at baseline.

No deficiencies cited during today’s inspection

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
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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