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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803994
Report Date: 09/20/2022
Date Signed: 09/20/2022 11:40:18 AM

Substantiated


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
06/23/2022 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20220623113941
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: 110DATE:
09/20/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Donald Stamets, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Call button in residents room not functioning
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Administrator, Donald Stamets.

Call button in residents room not functioning - Complainant alleges call button in R1’s room not functioning. From LPA’s observation of alarm test and bathroom call button pushed at 2:24pm on 7/21/2022, facility care staff 1 minute later knocked on door, opened, and came in. In addition, a second care staff came in within 15 seconds after 1st staff to check on resident. LPA observed staff turn off silent alarm located in the bathroom. LPA obtained copy of R1’s alarm history from 6/21/22 to 6/30/22 albeit Administrator has informed there is a glitch in the system, logging is absent from 6/21/22 through 6/27/22. Facility learned that call pendant that resident R1 was wearing on the morning of 6/25/2022, when R1 fell on hallway floor on way to the restroom was not working properly resulting in resident not being able to utilize call pendant and another pendant was given to R1. Per facility staff resident R1 has had approximately 2 pendants replaced per month.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 21-AS-20220623113941
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: 09/20/2022
NARRATIVE
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The preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 21-AS-20220623113941
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation 87303 (a)
(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement was not met as evidence by:
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Administrator to ensure the facility call devices are in working order and call recordings are properly keeping track. Submit plan of how facility will be in future compliance moving forward. POC due 10/4/22.
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Based on LPA's Interviews, and record review facility did not comply with the section cited above in maintaining the facility in good repair and keeping residents call devices in working order, which poses/posed 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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
06/23/2022 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20220623113941

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: 110DATE:
09/20/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Donald Stamets, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility did not maintain current records for client
Facility did not provide requested records to client authorized representative
Facility is retaliating for a prior complaint
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Administrator, Donald Stamets.

During investigation of allegation “facility did not maintain current records for resident”, Department learned that R1 had a physician’s assessment (LIC 602) upon admission to facility – resident R1 was admitted 6/16/2014 –Administrator informed this LIC602 was provided at move in with other required documentation for admission. The LIC602 provided had the error diagnosis and subsequent LIC 602s were found on file. It was observed during record review that R1’s diagnosis changed as per LIC 602 6/1/2021, and R1's most recent LIC 602 dated 4/2/2022. Resident R1 has diagnosis of MCI, therefore LIC602 not required per regulation to be updated annually. Furthermore, no other resident documents indicated diagnosis. Based on record review and interviews with staff and outside party, Department is not able to prove or disprove that current records were not maintained for resident. Therefore, the allegation is unsubstantiated.
Continue on LIC9099-C


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 21-AS-20220623113941
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: 09/20/2022
NARRATIVE
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LPA was able to obtain email throughout investigation. Email statement on April 2022 resident’s R1 Power of Attorney (POA) requested documentation which wasn’t provided. However, on 5/18/2022 there were several exchanges of emails between facility and POA which states that medical records were being requested which were provided on 6/30/2022. Facility attempted to submit files, however; due to digital files size being too large, facility contacted POA regarding this situation and left a copy at front desk for pickup on 7/2/2022. LPA is not able to prove or disprove that requested records were not provided to authorized representative since there were several documents provided on 7/2/2022. There is no Regulation regarding the timing to submit documents that might be requested by responsible parties. Therefore, the allegation is unsubstantiated.

The complainant alleges the facility is retaliating because of the rate increase. Based on LPA;s interviews and evidence provided by complainant of annual increase and care fees LPA was unable to obtain information to corroborate the allegation. According to records reviewed, facility has increased residents' rate due to a “Costumery annual increase in rent and care fees” and/or a change of condition that might occur at any time to a resident. Based on interviews and records reviewed, the Department can’t prove or disprove that there is retaliation due to prior complaint. Therefore, this allegation is unsubstantiated.

Although the allegations 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 allegations are Unsubstantiated.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
06/23/2022 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20220623113941

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: 110DATE:
09/20/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Donald Stamets, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility did not provide 60 days written notice for increase in rates
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Administrator, Donald Stamets.

Facility has a standard quarterly re-assessment that every resident receives each 3/months to ensure residents' needs are being met and any change of condition. On 6/18/2022 R1’s increased by a total of 40 points. Per interview with Administrator on 7/21/2022, “the residents’ points (care needs) increased - full toileting and status checks.” An email with a new care plan, resident’s needs, and increase of rate due to change on points was communicated to the R1’s POA on 6/20/2022. Facility offered on a follow up email in the same day 3 different dates w/ 6 different times to meet regarding change of care. Increase effective on July statement for 14 days in June. Per Health & Safety Code 1569.657 (a) for any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’ representative written notice of the rate increase within two business days after initially providing services.
Continue on LIC9099-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 21-AS-20220623113941
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: 09/20/2022
NARRATIVE
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In addition, on 3/31/2022 facility submitted a letter to all residents regarding “costumery annual increase in rent and care fees” which “would be affective on 6/1/2022. According to facility care plan program, points will start to increase when the care needs increase and will be reflected on the next billing cycle. Title 22 Regulation 87507 states that facility must give 60-day notice when there is any increase of its rate structures for services. Therefore, the allegation is Unfounded.

We have found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7