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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804321
Report Date: 08/04/2026
Date Signed: 08/04/2026 04:30:30 PM

Document Has Been Signed on 08/04/2026 04:30 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:AEGIS LIVING SAN RAFAELFACILITY NUMBER:
216804321
ADMINISTRATOR/
DIRECTOR:		ABUSBAITAN, RABAHFACILITY TYPE:
740
ADDRESS:800 MISSION AVETELEPHONE:
(415) 474-3333
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 98CENSUS: 59DATE:
08/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Administrator, Rabah Sbaitan, Health Services Director, Felicidad Ybona, and Care Director, Eugene PascualTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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At approximately 9:05AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Administrator, Rabah Sbaitan, Health Services Director, Felicidad Ybona, and Care Director, Eugene Pascual. Facility serves older adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Facility has a total capacity for 98 residents where 88 residents can be Non-Ambulatory and 10 residents can be Bedridden. Facility also has an approved hospice waiver for 16 individuals. Upon arrival, LPA was informed that there were 59 Residents in care.

LPA requested for a list of all staff members on-site in order to review the Guardian Staff Roster and associations. Upon review, it was discovered that 6 of 25 staff members were background cleared but were not associated to the facility per regulation. Review of Guardian Background Clearance and associations revealed that Staff Members 1, 2, and 3 were associated to the facility during LPA's visit at 10:33AM, 10:41AM, and 1:13PM. Staff Members 4, 5 , and 6 were not associated to the facility.

At approximately 10AM, LPA conducted a walk-though of the facility with Administrator and observed the following: Facility was clean and at a comfortable temperature with all exits free from obstruction. Facility is a 5 story building comprised of Assisted Living and Memory Care units. Facility has a large commercial kitchen with multiple food storage areas, a bistro, private dining room, offices, common spaces, and indoor and outdoor activity spaces. Facility's 2nd floor is designated for Memory Care while the 3rd, 4th, and 5th floors are designated for Assisted Living. Facility has two stairwells and were observed to have emergency evacuation chairs available on the 5th floor. Facility had emergency lighting. Facility has an Infection Control plan on file. Facility's delayed egress doors on the 2nd and 3rd floors were tested and operational. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility was observed to have an adequate supply of emergency water available in the event facility needs to shelter in place for 72 hours. Facility's emergency disaster plan was last reviewed and updated on June 2025.
Continued on LIC809C
Victoria Bertozzi
Caitlynn Felias
DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2026
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: AEGIS LIVING SAN RAFAEL
FACILITY NUMBER: 216804321
VISIT DATE: 08/04/2026
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Continued from LIC809

Facility had an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for a sample size of 12 sinks were found to be out of compliance with Title 22 Regulations measuring between 120.5F-124.5F. LPA and Administrator observed a bottle of allergy medication and pre-measured barrier cream and powder during walkthrough in memory care. These medications were located in two resident rooms in locked bathroom cabinets. LPA and Administrator also observed a bottle of cleaning solution accessible and unlocked under the sink located in the kitchen area on the third floor.

LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date to complete file review and medication audit.

**An immediate civil penalty assessment in the total amount of $600.00 has been issued for a violation of Regulation 87533(e)** (See LIC421FC)

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, Plan of Corrections, Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2026 04:30 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 08/04/2026 at 03:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AEGIS LIVING SAN RAFAEL
FACILITY NUMBER: 216804321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation 87303:(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above. 12 of 12 sinks were found to be out of compliance measuring at temperatures between 120.5F and 124.5F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2026
Plan of Correction
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Licensee to submit a self certification stating that a water temperature log will be done and submitted. Self Certification due by POC due date of 08/05/2026. Log to be started on 08/05/2026 and end on 05/14/2026. Log to include date, location of sink, water temperature, and time of temperature check. Log to be submitted to CCL by POC due date of 08/17/2026.
Type A
Section Cited
CCR
87355(e)
87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made and record review, Licensee did not comply with the section cited above. Licensee did not ensure that 6 out of 25 staff members had been associated to the facility prior working on-site and prior to LPA's visit. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2026
Plan of Correction
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Licensee to submit a written plan outlining how the facility will maintain compliance with regulation and ensure that facility staff members are associated to the facility once they have been background cleared. Plan to be submitted to CCL for review by POC due date of 08/05/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Caitlynn Felias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2026


LIC809 (FAS) - (06/04)
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