AEGIS LIVING CORTE MADERA

5555 PARADISE DRIVE, Corte Madera CA 94925

Facility 216803994 · RESIDENTIAL CARE ELDERLY (740)

150 bedsLatest official report May 5, 2026Licensed

Additional info
Licensee
BMSH II CORTE MADERA CA; AEGIS SENIOR COMMUNITIES
Administrator
TERRY BECHTOLD
Contact
TERRY BECHTOLD
License first date
May 6, 2022
License effective date
May 6, 2022
District office
SANTA ROSA RO · (707) 588-5026
Regional office
21
Clients served
983 - RCFE / DEMENTIA

Summary

The available records show 21 Type A and 8 Type B deficiencies for this facility.

Most recent inspection
May 5, 2026
Most recent deficiency
May 5, 2026

No later report is available, so the records do not show what happened afterward.

What Type A and Type B mean
Type A
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
Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.

Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.

At a glance

Counts cover the five-year public record. Typical figures are the median for the 12 Marin County facilities licensed for 50 or more beds, except where too few exist to state one — those come from facilities with 7 or more beds.

In the available public five-year record, CCLD published 37 reports for this facility: 20 inspections, 15 complaint investigations, and 2 licensing or administrative records.

Those records contain 21 Type A and 8 Type B deficiencies.

12 deficiencies have explicit official correction or clearance evidence in the loaded records.

Official inspections
20

More than the typical 12

4 in the last 12 months

Recorded deficiencies
29

Well above the typical 10

6 in the last 12 months

Type A deficiencies
21

Well above the typical 6

3 in the last 12 months

Type B deficiencies
8

More than the typical 7

3 in the last 12 months

Substantiated complaints
5

More than the typical 1

0 in the last 12 months

Repeated topics
5

Last 36 months

Repeated topics

Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.

Official report history

All preserved reports from the most recent to the oldest, sortable by report type.

Inspection
Facility condition and maintenanceType A
Official classification
Type A
Official code
87303(e)(2)
Regulation authority
CCR

What the official deficiency says

(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 Based on observations made, Licensee did not comply with the section cited above. 7 of 10 facility sinks were found to be out of compliance with Title 22 Regulations, measuring at 125.6F, 125.2F, 122.5F, 123.0F, 121.8F, 120.3F, 120.2F. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/06/2026 Plan of Correction 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 05/06/2026. Log to be started on 05/06/2026 and end on 05/16/2026. Log to include date, location of sink, water temperature, and time of temperature check and be submitted to CCL by POC due date of 05/18/2026.

Plan of correction recorded
Correction not verified in available records
View official report
Medication handling and storageType A
Official classification
Type A
Official code
87465(h)(2)
Regulation authority
CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made, Licensee did not comply with the section cited above. LPA observed two residents with medications in their room that should have been centrally stored and inaccessible. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/06/2026 Plan of Correction Licensee to submit a self certification stating that training will be conducted for all direct care staff by POC due date of 05/06/2026. Training to include: Trainer, Date of Training, Topic, Job Title, Staff Names and Signatures. Proof of training and supporting documents to be submitted for review and approval by POC due date of 05/18/2026.

Plan of correction recorded
Correction not verified in available records
View official report
Food serviceType B
Official classification
Type B
Official code
87555(a)
Regulation authority
CCR

What the official deficiency says

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made, Licensee did not comply with the section cited above. LPA observed expired yogurt in facility's memory care fridge located in Lee's Lane Memory Care. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/18/2026 Plan of Correction Licensee to conduct in-service training for direct care staff on food safety standards and expectations in Memory Care. Training to include: Trainer, Date of Training, Topic, Job Title, Staff Names and Signatures. Training to be submitted for review and approval by POC due date of 05/18/2026.

Plan of correction recorded
Correction not verified in available records
View official report
Inspection
Resident rightsType B
Official classification
Type B
Official code
87468.2(a)(4)
Regulation authority
CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights...: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are...to meet their needs. This requirement is not met as evidenced by: Based on interview & record review, the licensee did not comply with the section cited above in that R1's Individualized Service Plan was not followed when R1 was transferred by only one (1) staff member which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee or Administrator to conduct Care Plan training for staff members to reiterate that residents' Individualized Service Plans be followed and to submit proof of training to Community Care Licensing by POC due date of 3/11/2026.

Deadline recorded: Mar 11, 2026. A deadline is not proof that correction was completed.

Plan of correction recorded
Correction deadline recordedDeadline Mar 11, 2026
Correction not verified in available records
View official report
Medical and dental careType A
Official classification
Type A
Official code
87465(a)(4)
Regulation authority
CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical... shall be developed...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: Based on interview & record review, the licensee did not comply with the section cited above in that medications for resident R3 were given to resident R2, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee or Administrator to conduct Medication Policy training for the facility's Medical Technicians and submit proof of training to Community Care Licensing by POC due dater of 3/11/2026.

Deadline recorded: Mar 11, 2026. A deadline is not proof that correction was completed.

Plan of correction recorded
Correction deadline recordedDeadline Mar 11, 2026
Correction not verified in available records
View official report
Inspection
Medical and dental careType B
Official classification
Type B
Official code
87465(a)(5)
Regulation authority
CCR

What the official deficiency says

87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by: Based on record review and interview with HSD, the facility did not ensure R1, R2, & R3’s medications were given as prescribed by doctor as pharmacy did not send monthly refills on time which is also a pharmacy error which poses an immediate health and safety risk to resident in care.

Official plan of correction

LPA obtained investigation along with disciplinary action. LPA also obtained medical staff retraining on the cycle fill and reordering process of medications. Deficiency cleared at visit.

Deadline recorded: Sep 19, 2025. A deadline is not proof that correction was completed.

Official record says corrected or clearedRecorded in report dated Sep 18, 2025
Correction deadline recordedDeadline Sep 19, 2025
View official report
Inspection
Staffing, personnel, and trainingType A
Official classification
Type A
Official code
87411(a)
Regulation authority
CCR

What the official deficiency says

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on incident report and interview, facility did not provide supervision to R1 resulting in an elopement. The absence/lack of supervision is an immediate risk to the Health, Safety and Rights of resident in care

Official plan of correction

On 4/28/2025 GM submitted in-service training for staff (signed & dated) of elopement procedures. Lock box for access key installed in facility; access to exit memory courtyard gates now only to Med care mgrs.... & Maintenance staff. Sign above lock “Whoever unlocks the gates must stay and re-arm device”, failure to do so will result in termination. ****A civil penalty is being assessed for $500.00 POC cleared at time of visit

Deadline recorded: May 21, 2025. A deadline is not proof that correction was completed.

Official record says corrected or clearedOn or before May 20, 2025
Plan of correction recorded
Correction deadline recordedDeadline May 21, 2025
View official report
Inspection
Facility condition and maintenanceType A
Official classification
Type A
Official code
87303(e)(2)
Regulation authority
CCR

What the official deficiency says

(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 Based on LPA & Interim Admin's observation & interview during annual inspection, the licensee did not comply with the section cited above in 14 out of 15 faucets used by resident in care measured between 120.2 degrees F & 132 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2025 Plan of Correction Interim Administrator to submit a LIC 9098 self certification that hot water temperature has been adjusted with receipt from Plumer by POC date of 04/25/25 Additionally, Licensee to submit 14 day log of water temperature to ensure temperature is within regulation and submit to CCL by 05/09/25

Plan of correction recorded
Correction not verified in available records
View official report
Hazardous items and storageType A
Official classification
Type A
Official code
87309(a)
Regulation authority
CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA & Interim Administrators observations during Annual Inspection, the licensee did not comply with the section cited above in finding 4 storage closets ( in MC & AL) unlocked containing multiple gallons of pain, toxic chemicals, cement, cleaning products, etc.. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2025 Plan of Correction Administration shall provide refresher training for all staff on the requirements of 87309 and will provide proof of completion to CCL by POC date in order to clear the deficiency. (With topic, instructor & dated sign in log by employees).

Plan of correction recorded
Correction not verified in available records
View official report
Incident reportingType B
Official classification
Type B
Official code
87211(a)(1)(D)
Regulation authority
CCR

What the official deficiency says

87211(a)(1)(D):Reporting Requirements:(a) Each licensee shall furnish to the licensing agency...(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident.. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in not submitting 6 Required Incident Reports to CCL, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2025 Plan of Correction Licensee to provide training to staff who submit Reports to CCL and conduct practice test by 4/25/2025 to clear citation as Facility believes there is a falty fax issue.

Plan of correction recorded
Correction not verified in available records
View official report
Inspection
Dementia careType A
Official classification
Type A
Official code
87705(b)(2)
Regulation authority
CCR

What the official deficiency says

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** Based on record review it was found that resident (R1) had been reported by facility to be missing from facility care. R1 is diagnosed with dementia and based upon Physicians Report, requires special supervision for confusion and wander risk. This is an immediate health & safety risk to resident in care.

Official plan of correction

Facility provided Elopement in-service training conducted, for regulation 87705 Care of Persons with Dementia with staff. In addition, a plan of how residents in Memory Care will be kept safe from wandering when landscaping company cuts grass. LPA Obtained copy of trainings w signatures and dates. Including, new plan for days when gardeners come. Citation cleared at visit....

Deadline recorded: Sep 27, 2024. A deadline is not proof that correction was completed.

Official record says corrected or clearedRecorded in report dated Sep 26, 2024
Plan of correction recorded
Correction deadline recordedDeadline Sep 27, 2024
View official report
Complaint

Allegations0 substantiated · 1 unsubstantiated · 0 unfounded

No deficiencies recorded in this report
Inspection
Medical and dental careType A
Official classification
Type A
Official code
87465(a)(5)
Regulation authority
CCR

What the official deficiency says

87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by: Based on record review and interview with GM & HSD, the facility did not ensure R1 medications were given as prescribed by doctor which poses an immediate health and safety risk to resident in care.

Official plan of correction

LPA obtained investigation along with disciplinary action. LPA is requesting facility to provide name of training company by POC due date of 4/26/2024 & for LPA facility to conduct Internal medication training from person outside of organization to all staff providing ...... medication on all shifts and submit log in sheet with written staff names & signatures w/ date and signed by trainer by POC due date 5/9/2024 to clear POC. Civil Penalties for $1000 for 3rd repeat violation of same deficiency in less than 12 months.

Deadline recorded: Apr 26, 2024. A deadline is not proof that correction was completed.

Plan of correction recorded
Correction deadline recordedDeadline Apr 26, 2024
Correction not verified in available records
View official report
Inspection
Medical and dental careType A
Official classification
Type A
Official code
87465(a)(5)
Regulation authority
CCR

What the official deficiency says

87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by Based on record review and interview with GM & HSD, the facility did not ensure R1-R2 medications were given as prescribed by doctor on 2 different incidents which poses an immediate health and safety risk to resident in care.

Official plan of correction

LPA obtained log of in-service trainings with signatures regarding medication handling & investigations. POC has been cleared at today's visit. Civil Penalties for $250 for repeat violation of same deficiency in less then 12 months.

Deadline recorded: Apr 4, 2024. A deadline is not proof that correction was completed.

Official record says corrected or clearedOn or before Apr 3, 2024
Correction deadline recordedDeadline Apr 4, 2024
View official report
Inspection
Dementia careType A
Official classification
Type A
Official code
87705(f)(1)
Regulation authority
CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs & General Manager's observation, the licensee did not comply with the section cited above when touring memory care courtyard observed large shards of broken glass on the ground by walkway accessible to residents in memory care, which poses an immediate health, safety or personal rights risk to persons in care. Maintance remived immediately.

Official plan of correction

POC Due Date: 04/04/2024 Plan of Correction Licensee to submit 1) Self-Certification stating that training will be conducted with facility staff, 2) an In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(1). Self Certification to be submitted to Community Care Licensing (CCL) by POC due date of 4/4/2024, and Training to be submitted by due date of 4/12/2024.

Plan of correction recorded
Correction not verified in available records
View official report
Dementia careType A
Official classification
Type A
Official code
87705(f)(2)
Regulation authority
CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs and General Managers observation, the licensee did not comply with the section cited above when touring memory care kitchenette finding Clorox toilet cleaning in unlocked cabinet which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/04/2024 Plan of Correction Licensee to submit 1) Self-Certification stating that training will be conducted with facility staff, 2) an In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(2). Self Certification to be submitted to Community Care Licensing (CCL) by POC due date of 4/4/2024, and Training to be submitted by due date of 4/12/2024.

Plan of correction recorded
Correction not verified in available records
View official report
Staffing, personnel, and trainingType B
Official classification
Type B
Official code
87411(f)
Regulation authority
CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's interview & record review, the licensee did not comply with the section cited above in 1 out of 5 staff did not obtain Health Screening test & TB test results which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2024 Plan of Correction Licensee to have all staff obtain a health screening with TB test and submit copies to Community Care Licensing for review by POC due date 4/17/2024. Licensee to notify CCL if more time is needed.

Plan of correction recorded
Correction not verified in available records
View official report
Facility condition and maintenanceType B
Official classification
Type B
Official code
87303(a)
Regulation authority
CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and General Manager's observation, the licensee did not comply with the section cited above in that a memory care residents bathroom window (that was open without a censor) did not contain required window screen, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/04/2024 Plan of Correction Facility replaced screen during LPA inspection. Deficiency cleared.

Official record says corrected or clearedOn or before Apr 3, 2024
Plan of correction recorded
View official report
Facility condition and maintenanceType B
Official classification
Type B
Official code
87303(e)(2)
Regulation authority
CCR

What the official deficiency says

87303(e)(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 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs and Licensee observation, the licensee did not comply with the section cited above in one memory care residents faucet was only 67 degrees F , which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2024 Plan of Correction Licensee will to submit as proof of correction a 2 week measurement log of water temperature readings, taken once in the morning and once at night, showing temperatures in compliance with regulation 87303(e)(2).

Plan of correction recorded
Correction not verified in available records
View official report
Inspection
Medical and dental careType A
Official classification
Type A
Official code
87465(a)(5)
Regulation authority
CCR

What the official deficiency says

87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by: Based on record review and interview with GM & HSD, the facility did not ensure R1-R4 medications were given as prescribed by doctor on 4 different incidents which poses an immediate health and safety risk to resident in care.

Official plan of correction

LPA obtained log of in-service trainings with signatures regarding medication handling & investigations. HSD has informed Med Techs on duty have been provided numbers to contact if unable to complete med pass. POC has been cleared at today's visit. Civil Penalties for $250 for repeat violation of same deficiency in less then 12 months.

Deadline recorded: Feb 12, 2024. A deadline is not proof that correction was completed.

Official record says corrected or clearedOn or before Feb 12, 2024
Correction deadline recordedDeadline Feb 12, 2024
View official report
Dementia careType A
Official classification
Type A
Official code
87705(b)(2)
Regulation authority
CCR

What the official deficiency says

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 Based on a record review & interview with GM it was found that resident (R5) had been reported by facility to be missing from facility care. Medical documents indicate diagnosis of dementia.

Official plan of correction

Facility conducted care confrence with family and moved R5 to memory care unity within the week of incident. POC has been cleared at today's visit. Civil Penalties for $250 for repeat violation of same deficiency in less then 12 months.

Deadline recorded: Feb 13, 2024. A deadline is not proof that correction was completed.

Official record says corrected or clearedOn or before Feb 12, 2024
Correction deadline recordedDeadline Feb 13, 2024
View official report
Complaint

Allegations0 substantiated · 1 unsubstantiated · 0 unfounded

No deficiencies recorded in this report
Complaint

Allegations0 substantiated · 1 unsubstantiated · 0 unfounded

No deficiencies recorded in this report
Inspection
Medication handling and storageType A
Official classification
Type A
Official code
87465(c)(2)
Regulation authority
CCR

What the official deficiency says

87465 (c )(2) Incidental Medical & Dental Care 87465(c)(2) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on self-report submitted by facility, a staff, provided another resident’s PRN pain medication to a resident, not administering PRN medication to R1 as prescribed by their Physician which is an immediate Health and Safety risk to the resident(s) in care.

Official plan of correction

LPA was provided Signed documentation of Policy and procedure review with Staff (S1) as well as In-Service training of Medication error protocol, Documentation Standards for Medication Policy, & Controlled Substance Medication protocol. POC cleared at time of visit. POC cleared at time of visit.

Deadline recorded: Dec 1, 2023. A deadline is not proof that correction was completed.

Official record says corrected or clearedOn or before Nov 30, 2023
Correction deadline recordedDeadline Dec 1, 2023
View official report
Complaint

Allegations1 substantiated · 1 unsubstantiated · 0 unfounded · 1 cited

Medical and dental careType A
Official classification
Type A
Official code
87465(a)(4)
Regulation authority
CCR

What the official deficiency says

87465(a)(4) Incidental Medical and Dental Care… The plan shall… provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medications as needed. *** Based on statements and documents, this requirement not met as evidenced by: PRN medication ordered by physician for R1 was not administered on 9/12/23. This posed an immediate risk to R1’s health. $250.00 Civil Penalty issued for repeat violation within 12 months.

Official plan of correction

Administration will provide refresher training in medication administration for all staff who administer medications. Training to include addressing issues identified by this complaint. Proof of training to be submitted to CCL by POC date in order to clear the deficiency. ***This is an amended version of the original report******

Deadline recorded: Nov 21, 2023. A deadline is not proof that correction was completed.

Plan of correction recorded
Correction deadline recordedDeadline Nov 21, 2023
Correction not verified in available records
View official report
Complaint

Allegations0 substantiated · 2 unsubstantiated · 0 unfounded

No deficiencies recorded in this report
Complaint

Allegations0 substantiated · 1 unsubstantiated · 0 unfounded

No deficiencies recorded in this report
Complaint

Allegations0 substantiated · 1 unsubstantiated · 0 unfounded

No deficiencies recorded in this report
Complaint

Allegations0 substantiated · 3 unsubstantiated · 0 unfounded

No deficiencies recorded in this report
Complaint

Allegations1 substantiated · 4 unsubstantiated · 1 unfounded · 1 cited

Staffing, personnel, and trainingType A
Official classification
Type A
Official code
87411(a)
Regulation authority
CCR

What the official deficiency says

87411(a) Personnel Requirements – General- (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on LPA interview’s and record review facility has delayed call response for residents using their pendants. From 3/1/2023-3/20/2023 reflect at least six hundred and fifty-four response times between 10-30 minutes, and at least 66 response times between 30-60 minutes, and at least 43 response times that were more than 60 minutes or never responded to. This is an immediate risk to the Health, Safety and Personal Rights of residents in care.

Official plan of correction

Administrator to ensure staff training on time management, buddy system and concierge coverage to alert approaching alloted time of bells is near are in place to meet the needs of residents. LPA provided copies of traings. POC cleared at time of visit.

Deadline recorded: Jul 7, 2023. A deadline is not proof that correction was completed.

Official record says corrected or clearedOn or before Jul 6, 2023
Correction deadline recordedDeadline Jul 7, 2023
View official report
Complaint

Allegations0 substantiated · 1 unsubstantiated · 2 unfounded

No deficiencies recorded in this report
Inspection
Medical and dental careType A
Official classification
Type A
Official code
87465(a)(5)
Regulation authority
CCR

What the official deficiency says

87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by: Based on record review and interview with Director of Operations, the facility failed to ensure R1-R13 medications were given as prescribed by doctor (not provided at evening med pass) which poses an immediate health and safety risk to resident in care.

Official plan of correction

POC- Administrator agrees to submit log of in-service additional training regarding medication handling by POC due date, 6/15/2023. Director of Operations has informed Med Tech on duty has been provided numbers to contact if unable to complete med pass .. alone and with all other med tech’s has received training on policies & procedures of Med pass routine & will continue medication training 1 day per week for 3 more weeks after this week. POC has been cleared at today’s visit.

Deadline recorded: Jun 15, 2023. A deadline is not proof that correction was completed.

Official record says corrected or clearedOn or before Jun 15, 2023
Plan of correction recorded
Correction deadline recordedDeadline Jun 15, 2023
View official report
Inspection
Dementia careType A
Official classification
Type A
Official code
87705(b)(2)
Regulation authority
CCR

What the official deficiency says

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** 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.

Official plan of correction

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.

Deadline recorded: Apr 12, 2023. A deadline is not proof that correction was completed.

Plan of correction recorded
Correction deadline recordedDeadline Apr 12, 2023
Correction not verified in available records
View official report
Complaint

Allegations0 substantiated · 1 unsubstantiated · 0 unfounded

No deficiencies recorded in this report
Complaint

Allegations1 substantiated · 1 unsubstantiated · 0 unfounded · 1 cited

Staffing, personnel, and trainingType A
Official classification
Type A
Official code
87411(a)
Regulation authority
CCR

What the official deficiency says

87411(a) Personnel Requirements – General- (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on LPA interview’s and record review facility has delayed call response for residents using their pendants. From1/23/2023-2/3/2023 reflect at least three hundred and one response times between 10-30 minutes, and at least 37 response times between 30-60 minutes. This is an immediate risk to the Health, Safety and Personal Rights of residents in care.

Official plan of correction

Administrator to ensure staff training on time management, buddy system and concierge coverage to alert approaching alloted time of bells is near are in place to meet the needs of residents. Training schedule of type due to CCL by 4/12/23 Sufficient training for staff on required time response due to CCL by COB 4/20/2023.

Deadline recorded: Apr 12, 2023. A deadline is not proof that correction was completed.

Plan of correction recorded
Correction deadline recordedDeadline Apr 12, 2023
Correction not verified in available records
View official report
Inspection
Medical and dental careType A
Official classification
Type A
Official code
87465(a)(4)
Regulation authority
CCR

What the official deficiency says

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 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.

Official plan of correction

POC Due Date: 03/22/2023 Plan of Correction Facility conducted additional training in Medication trainig, deficiency cleared during this visit.

Official record says corrected or clearedRecorded in report dated Mar 22, 2023
Plan of correction recorded
View official report
Complaint

Allegations0 substantiated · 1 unsubstantiated · 0 unfounded

No deficiencies recorded in this report
Complaint

Allegations1 substantiated · 3 unsubstantiated · 1 unfounded · 1 cited

Facility condition and maintenanceType B
Official classification
Type B
Official code
87303(a)
Regulation authority
CCR

What the official deficiency says

Maintenance and Operation 87303 (a) (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement was not met as evidence by: Based on LPA's Interviews, and record review facility did not comply with the section cited above in maintaining the facility in good repair and keeping residents call devices in working order, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator to ensure the facility call devices are in working order and call recordings are properly keeping track. Submit plan of how facility will be in future compliance moving forward. POC due 10/4/22.

Deadline recorded: Oct 4, 2022. A deadline is not proof that correction was completed.

Plan of correction recorded
Correction deadline recordedDeadline Oct 4, 2022
Correction not verified in available records
View official report
Complaint

Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited

Staffing, personnel, and trainingType A
Official classification
Type A
Official code
87411(a)
Regulation authority
CCR

What the official deficiency says

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee/Administrator did not ensure staff was competent and or knowledgeable to be able to administer per doctor orders. Staff could not find the mask needed which is an immediate risk to the health and safety of residents in care.

Official plan of correction

The facility conducted a staff training on 6/1/2022 to address the situation with locating R1s mask to administer PRN medication timely. LPA obtain a copy of training sign in sheet at time of inspection, Citation cleared 6/14/2022.

Deadline recorded: Jun 15, 2022. A deadline is not proof that correction was completed.

Official record says corrected or clearedOn Jun 14, 2022
Correction deadline recordedDeadline Jun 15, 2022
View official report
Licensing recordNot an inspection of the operating facility
No deficiencies recorded in this report
Licensing recordNot an inspection of the operating facility
No deficiencies recorded in this report

Source and limits

California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.

Read the data methodology