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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803994
Report Date: 03/22/2023
Date Signed: 03/22/2023 02:27:35 PM


Document Has Been Signed on 03/22/2023 02:27 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: 117DATE:
03/22/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Donald Stamets, Administrator and Business Office Manager Rukhshana ShahTIME COMPLETED:
02:30 PM
NARRATIVE
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License Program Analyst's (LPA’s) Shannan Hansen and Victoria Bertozzi arrived at 9:00 AM to complete an unannounced annual inspection and met with Donald Stamets, Administrator. There is a total of 117 residents.

LPA's reviewed centrally stored medication record, and conducted staff interviews to complete this annual inspection.

During inspection LPA's followed up on medication error that was self reported to community care licensing on 3/16/2023. Resident had a change of dosage that was not carried out for almost 2 months after doctor changed order. Conversation with Administrator indicated facility has made changes to medication entering policies to prevent future medication errors.


LPA Hansen is requesting Licensee to update and submit the following documents by 4/22/2023 to SRRO:

LIC 308 Designation of Facility Responsibility

LIC 500 Personnel Record

LIC 610 Emergency Disaster Plan (if changes)

Copy of Administrator Certificate

Proof of Liability Insurance

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: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
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 03/22/2023 02:27 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: 03/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)


A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above where resident was not assisted with eyedrops per doctors orders, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2023
Plan of Correction
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Facility conducted additional training in Medication trainig, deficiency cleared during this visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
LIC809 (FAS) - (06/04)
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