216804321-4-15-2026-21-AS-VBEI-DTFPJD-20260424112118

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804321
Report Date: 04/15/2026
Date Signed: 04/15/2026 12:51:44 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/28/2026 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20260128145923

FACILITY NAME:	AEGIS LIVING SAN RAFAEL		FACILITY NUMBER:	216804321
ADMINISTRATOR:	ABUSBAITAN, RABAH		FACILITY TYPE:	740
ADDRESS:	800 MISSION AVE		TELEPHONE:	(425) 861-9993
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	98	CENSUS: 48	DATE:	04/15/2026
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator, Rabah Sbaitan, and Health Services Director, Felicidad Ybona		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Personal Rights

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 21-AS-20260128145923

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/15/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20260128145923

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/15/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 21-AS-20260128145923

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/15/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/27/2026 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	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	1 2 3 4 5 6 7	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
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14	due date of 04/27/2026.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4