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Inspection visit

Routine inspection

AEGIS LIVING CORTE MADERALicense 2168039943 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

At approximately 9:05AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1 year required visit and met with Administrator, Eugene Pascual, and Executive Director, Terry Bechtold. 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 150 residents and an approved fire clearance for 150 non-ambulatory residents, of which 35 residents can be bedridden. Facility has an approved hospice waiver for 25 individuals. Upon arrival, LPA was informed that there were 118 Residents in care and 47 staff members on-site. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with Administrator and Executive Director and observed the following: Facility is a 2-story building for Assisted Living and Memory Care. Facility's Memory Care consists of two areas - Lee's Lane and Hogan's Court. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. Emergency evacuation chairs were observed at facility stairwells. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was 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. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for 7 of 10 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 . Facility's fire extinguishers and smoke and carbon monoxide detectors were last inspected January 2026. Facility's fire and sprinkler system was last inspected June 2025. Continued on LIC809C Continued LIC809C Facility's emergency disaster plan was last reviewed and updated on 10/15/2025. Facility's infection control plan was last reviewed and updated 01/05/2026. Facility was observed to have enough water available in the event facility had to shelter in place for 72 hours. Facility's last emergency disaster drill was conducted April 2026. LPA observed that facility only conducted emergency disaster drill for the morning shift. Facility was unable to provide proof that drill was conducted for evening and overnight shifts. LPA discussed the importance of ensuring that all shifts receive the emergency disaster drill training every quarter. During walkthrough, LPA observed a carton of expired yogurt located in the dining room fridge of Lee's Lane Memory Care. Executive Director disposed of the item. LPA, Administrator, and Executive Director also observed medications in two resident rooms. LPA and Administrator confirmed with Facility's Wellness Director that these two residents are receiving assistance with medications and therefore their medications should be centrally stored. Administrator's Certificate Terry Bechtold (6079066740) was current with an expiration of 10/02/2027, Administrator's Certificate for Eugene Pascual (7037022740) was shown to be pending, with an application received date of 04/08/2026. LPA began staff file review. LPA discussed the following with Administrator and Executive Director: Reporting Requirements PIN regarding 911 protocols PIN regarding dementia regulations LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. 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 and Executive Director. Signature on form confirms receipt of documents.

Citations

4 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87303(e)(2)Type A

    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.

  • 87465(h)(2)Type A

    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.

  • 87555(a)Type B

    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.

  • 87211(a)(1)(D)Type B

FAQ · About this visit

Common questions about this visit

What happened during the May 5, 2026 inspection of AEGIS LIVING CORTE MADERA?

This was a inspection inspection of AEGIS LIVING CORTE MADERA on May 5, 2026. 3 citations were issued: 2 Type A (serious) and 1 Type B.

Were any citations issued to AEGIS LIVING CORTE MADERA on May 5, 2026?

Yes, 3 citations were issued (2 Type A, 1 Type B). The first citation was for: "Based on observations made, Licensee did not comply with the section cited above. 7 of 10 facility sinks were found to b..."

What type of inspection was this?

This was a inspection inspection. inspection inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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