Aegis Living San Rafael

Type of visit: Required - 1 Year

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 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.the state’s words, verbatim · CDSS document, Aug 4, 2026

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Personal Rights

At approximately 11:00AM, Licensing Program Analyst (LPA) Felias, arrived unannounced to deliver findings for a complaint investigation regarding the above allegation and met with Administrator, Rabah Sbaitan, and Health Services Director, Felicidad Ybona. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Personal Rights.” Complaint alleged that Resident 1 (R1) was physically abusing their partner, Resident 2 (R2). Continued on LIC9099C Substantiated Continued from LIC9099 Review of R1’s file showed that they moved to the facility with R2 in December 2025. The following entries were observed in R1’s progress notes: 12/27/2025: R2 voiced safety concerns about R1, stating that R1 has been showing abnormal behaviors such as being very angry and having verbal arguments with them. R2 expressed concerns that R1 could escalate the arguments physically. Per progress note, facility staff reached out to R1’s physician and R2 was instructed to press their pendant if they feel unsafe, to leave the room and find the nearest staff member. 01/04/2026: R1 became agitated and elbowed R2. R2 pressed their pendant and facility staff observed R1 threatening and attempting to grab the pendant out of R2’s hands in an attempt to prevent them from calling for help. R1 pushed R2 down on the bed. Facility staff intervened and were instructed to call emergency services if the situation escalated. Progress note also stated that an hour later R1 seemed confused. 01/05/2026: Facility staff, R1 and their POA held a meeting to discuss R1’s behaviors towards R2. Per notes, R1 was informed that they need to have another medical assessment and that aggressive behavior would be reported. Notes also stated that R1’s physician had been contacted multiple times. 01/20/2026: R1 was on alert charting for aggressive behavior and high blood pressure. Per interview with Health Services Director, alert charting is done for any unusual incident or change of condition for residents and is usually done for at least 72 hours or until the situation has been resolved. 01/24/2026: R1 had a phone call with their physician to address concerns related to their aggressive behavior and other medical concerns. R1’s Individualized Service Assessment dated 09/24/2025 stated that R1 did not have any behaviors that required staff intervention. R1’s Assisted Living Assessment dated 01/13/2026, stated that R1 did not have any behaviors that require staff intervention. Continued on LIC9099C Continued from LIC9099C Interview conducted with Health Services Director revealed that R1 and R2 have not received an updated care plan since 01/13/2026. Per interview, R1 and R2 have not been placed on frequent checks due to being very independent and are checked by facility staff at the beginning and end of each shift. Per Health Services Director, frequent checks would be done either every hour or every half hour if implemented. Interview further revealed that R1 and R2 do not have a one-on-one for supervision and that R2 has been instructed to call for help by pressing their pendant in the event they feel unsafe with R1. Per interview, facility staff try to respond to pendant calls in 10 minutes or less. Based on record review, interviews conducted, and observations made, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 21-AS-20260128145923

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 27, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities:(a) In addition to the rights listed in Section 87468.1... residents...shall have all of the following...: (4) To care, supervision, and services that meet their individual needs and are delivered by staff...this requirement was not met as evidenced by: based on records, interviews & observations made, Licensee did not comply with the section cited above and did not ensure that R2 received supervision to met their individual needs.This poses a potential health/safety/personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Licensee to conduct a reassessment of R1 and R2, update their care plans to meet their current care needs and inform their responsible parties. Proof of updated assessments and care plan, and additional supporting documents to be submitted to CCL for review and approval by POC due due date of 04/27/2026.

Type of visit: Case Management - Incident

At approximately 9:10AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit, and met with Administrator, Rabah Sbaitan, and Health Services Director, Felicidad Ybona, and Regional Care Director, Ticarra Boyd. The purpose of the visit was to follow up on self-reported incident reports submitted to Community Care Licensing. Incident Report 1: The Santa Rosa Regional Office (SRRO) received a report on 12/23/2025. Report stated that on 12/21/2025, Resident 1 (R1) exited the facility through the egress doors after pulling the emergency alarm. Facility implemented their elopement protocols and notified San Rafael Police Department (SRPD). R1 was found three blocks from the facility by SRPD. Facility made all appropriate notifications per regulation. Review of R1's file showed that they are unable to leave the facility unsupervised or without an escort per their Physician Report dated 11/14/2025 and Care Plan. Facility conducted elopement training on 12/24/2025. Deficiency issued today has been cleared and Plan of Corrections Letter provided during visit. Incident Report 2: The SRRO received a report on 03/17/2026. Report stated that on 02/17/2026, Resident 2 (R2) was evaluated by a wound specialist. Additional information provided to the Department revealed that on 02/17/2026, the wound specialist believed that R2's wound could be unstageable but further testing would be needed to confirm. On 03/17/2026, the wound specialist conducted additional tests where it was determined that R2's wound was a Stage 2 pressure ulcer. Continued on LIC809C Continued from LIC809 Department did not receive an exception to retain a resident with a prohibited condition once it was believed that R2 could have had an unstageable wound in February 2026. 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, LIC809D (Deficiency Page), Plan of Corrections, Appeal Rights, and Plan of Corrections Letter discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 26, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(e)(7) · Plan of correction due date: Apr 6, 2026

87705 Care of Persons with Dementia (e) Licensees that use delayed egress devices... shall meet the following...requirements: (7) Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents...this requirement was not met as evidenced by: based on record review, Licensee did not comply with the section cited above. Resident 1 (R1) eloped from the facility. R1's physician report & care plan showed R1 is unable to leave unassisted. This poses an potential health/safety/personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: Licensee provided proof of elopement training dated 12/24/2025. Deficiency cleared during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87616(a) · Plan of correction due date: Apr 6, 2026

87616 Exceptions for Health Conditions (a) ...the licensee may submit a written exception request if he/she agrees that the resident has a prohibited... health condition but believes that the intent of the law can be met through alternative means. This requirement was not met as evidenced by: based on record review and interviews, Licensee did not submit the proper paperwork to Community Care Licensing once it was believed that R1 had an unstageable wound. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: Licensee to conduct in-service training for all direct staff reviewing the following regulations: 87616 Exceptions for Health Conditions and 87615 Prohibited Health Conditions. Training to include the following: Date, Topic, Job Role, Staff Names, and Signatures. In-Service and supporting documents to be submitted to CCL for review and approval by POC due date of 04/06/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 6, 2026

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted...within seven days of the occurrence of any of the events specified...below. This requirement was not met as evidenced by: Licensee did not comply with section cited above. Per record review, Licensee did not submit incident reports timely. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: Licensee to conduct inservice-training on Reporting Requirements. Training to include the following: Date, Topic, Name/Job Role, and Signatures. In-Service and supporting documents to be submitted to CCL for review and approval by POC due date of 04/06/2026.

Type of visit: Prelicensing

At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived announced to conduct a Pre-Licensing Inspection and met with Applicants, Ana de la Cerda and Rabah Sbaitan. Upon arrival, LPA was informed that there were currently no residents in care. Facility received an approved fire clearance dated 08/21/2025 that allows for a total capacity of 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 and a Dementia Care Program on file. LPA conducted a walk-though of facility with Applicants and observed the following: 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 had emergency evacuation chairs available on the 5th floor. Facility was clean and at a comfortable temperature with all exits free from obstruction. Facility has emergency lighting. Facility has an Infection Control plan on file. A sample size of 10 facility sinks were found to be within Title 22 Regulations of 105F to 120F. Bathrooms and showers were textured and equipped with necessary grab bars for safety. Facility will have a medication cart for each floor with extra medications stored in the nurse's station. Facility files will be accessible electronically. Facility will be utilizing a call light system. LPA observed appropriate amount of emergency water and food supply available. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility will be increasing food delivery as facility's population increases. Facility's fire extinguishers were inspected May 2025. Facility smoke and carbon monoxide detectors were tested by the Fire Marshal on 08/21/2025. Facility's First Aid Kits were sufficient. Required posters for Long Term Care Ombudsman and Complaints were located by the General Manager's Office. Continued on LIC809C Continued from LIC809 Per conversation with VP of Regulatory Affairs and Senior General Manager, facility will have caregivers and medication technicians available 24/7 while nurses will be available 7 days of the week from 7AM-8PM. Component III was reviewed with Applicants. Facility to submit to proof that building is clean and cleared of all construction equipment prior to having residents move in. Proof to be submitted to Community Care Licensing (CCL) by Tuesday, 09/02/2025. No Deficiencies or Advisories given during visit. Pre-Licensing completed. Facility is ready to be Licensed as a Residential Care Facility for the Elderly. LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Analyst will notify Applicant of Status. Exit interview conducted. Copy of report discussed and provided to Applicants. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Aug 26, 2025

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 98 Interview Method: Telephone interview On 8/22/2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Aug 22, 2025