216803994-3-16-2023-21-AS-SHAN-CPYUSV-20230316155058

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216803994
Report Date: 03/16/2023
Date Signed: 03/16/2023 03:51:08 PM

Document Has Been Signed on 03/16/2023 03:51 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: 115	DATE:	03/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Donald Stamets, Administrator and Business Office Manager Rukhshana Shah		TIME COMPLETED:	04:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

License Program Analyst's (LPA’s) Shannan Hansen and Victoria Bertozzi arrived at 8:45 AM to conduct an unannounced annual inspection and was greeted by Donald Stamets, Administrator. Administrator was unable to attend full inspection so the Business Office Manager signed report. There is a total of 115 residents, of which 35 dementia residents, and 9 residents under Hospice care.

Facility tour/inspection began at 9:35 AM:

Beginning at approximately 9:33 AM, LPA's toured the community with Administrator Donald Stamets and Maintenance Director Jose Herrera. The tour of the facility included nine resident apartments, activity rooms, Library, Salon, dining rooms, kitchen and outdoor patios. All interior parts of the facility were found to be a comfortable temperature measuring between 75 to 78 degrees F. Exits and pathways were free from obstructions. The assisted living residents also have an outdoor patio courtyard. Delayed egress doors from the memory care units (Lee’s Lane & Hogan’s Court) have audible alarms when doors are opened without access codes. Hot water temperature measured within regulation of 105 to 120 degrees F in nine of nine rooms tested. Bathrooms contained necessary grab bars and showers contained non-slip floor/mats. LPA's observed at least a minimum of a 2 day supply of perishable and 7 day supply of non-perishable food necessary for residents in care. Food was found to be handled and stored in a safe manner. Dining rooms and kitchen were inspected and maintained per regulation. Menus with snack and beverages are available to residents. Activity schedules are posted. Facility has a theater and multiple indoor and outdoor sitting areas and a private dining area.

Continued on LIC809C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/16/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC809

Fire extinguishers were last serviced 1/3/2023. Fire safety system including smoke detectors and carbon monoxide detectors are checked quarterly by facility staff and are on a regular service schedule with a vendor.

LPAs initiated a file review of five resident files and five personnel files but were unable to complete. LPAs were also unable to review medication and will return at a later date to complete annual inspection.

No deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2