216803994-2-26-2023-21-AS-BMOS-CPGQXT-20230228113404

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803994
Report Date: 02/24/2023
Date Signed: 02/26/2023 11:01:38 AM

Unsubstantiated

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
11/15/2022 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20221115134740

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: 118	DATE:	02/24/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Nithi Narasappa, Director of Operations		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Staff is not adequately trained

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 Director of Operations, Nithi Narasappa as Administrator Donald Stamets out.

Staff is not adequately trained – Complainant alleges staff is not properly trained. The LPA reviewed information provided by the reporting party. The LPA reviewed resident records (R1), including care plan, medical records, incidents, medication records, and progress notes. Per interviews and records reviewed the nebulizer at time staff was attempting to use appeared to be not functioning correctly. Staff attempted to contact RP and as a result contacted 911. The nebulizer was stored in resident’s room and interviews revealed, may have been tampered with. Per Fire Department report resident was assisted with fixing nebulizer. LPA reviewed staff training records. The LPA conducted interviews with staff (S1&S2) The investigation revealed that the staff have the training required.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20221115134740

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: 02/24/2023

NARRATIVE

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Staff have had training in resident transfers, and in caring for residents with dementia/memory loss. Staff have had elder abuse training as required and have had training in Medication Management and understanding Side Effects, or any resident incidents that may occur. Staff stated that they do training all the time, it is ongoing. To assist the residents with their care needs, bathing, grooming, incontinence care, transfers, medication assistance, and other care services as needed. LPA interviewed staff that were able to provide information of their job duties, and the training provided to them which LPA observed in training records. To prevent from occurring again facility has put a plan in place to avert such incidences by keeping the nebulizer in a locked cabinet in the resident’s room that all staff will have a key to, to minimize damage and a spare nebulizer in the medication cart. Facility held an in-service training for care managers and medication technicians regarding nebulizer applications.

Based on LPAs observations, record reviews, interviews with staff, and conflicting information obtained from other related parties, there is insufficient information to prove or disprove the allegation Staff is not adequately trained. Although the allegation 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 allegation is Unsubstantiated.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC9099 (FAS) - (06/04)

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