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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803994
Report Date: 04/11/2023
Date Signed: 04/11/2023 02:31:50 PM


Document Has Been Signed on 04/11/2023 02:31 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: 116DATE:
04/11/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Donald Stamets, AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management and met with Administrator Donald Stamets. The purpose of this case management inspection is to follow up on a self-reported incident report submitted to Community Care Licensing (CCL).

CCL received a self-report incident report form on 3/28/2023 reporting on 3/17/2023 at approximately 9pm resident (R1) had eloped from community. Facility staff and law enforcement conducted search and located R1. Law enforcement returned R1 to community approximately 30 minutes later. LPA obtained records indicating R1 has diagnosis of dementia and is not to leave unassisted. LPA is issuing a citation today for R1 eloping from facility without staff knowledge on 3/17/2023. Administrator has informed R1's spouse has moved into facility relieving R1 of exit seeking at this time.

Appeal of Rights Given.



The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
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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Document Has Been Signed on 04/11/2023 02:31 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2023
Section Cited

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87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by**
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Facility provided in-service training conducted, for regulation 87705 Care of Persons with Dementia with staff. But has not submitted LIC9098 with date & signatures of staff, to be submitted by 4/12/2023.
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Based on a review records it was found that resident (R1) had been reported by facility to be missing from facility care. Medical documents indicate diagnosis of dementia.
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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: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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