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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001170
Report Date: 05/26/2021
Date Signed: 05/26/2021 03:14:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AEGIS ASSISTED LIVING OF DANA POINTFACILITY NUMBER:
306001170
ADMINISTRATOR:SHEILA NAZARETHFACILITY TYPE:
740
ADDRESS:26922 CAMINO DE ESTRELLATELEPHONE:
(949) 488-2650
CITY:DANA POINTSTATE: CAZIP CODE:
92624
CAPACITY:76CENSUS: 60DATE:
05/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Sheila Nazareth and Joe DaldrupTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on an SOC 341 received by Community Care Licensing (CCL) on 05/13/2021. LPA met with Health Services Director/ Administrator Sheila Nazareth and explained the reason for the visit. Executive Director Joe Daldrup was present as well.

Incident report dated 05/13/2021 indicated Resident 1 (R1) reported having painful pressure put on the resident by an unknown assailant. R1 was noted to have bruising on hands and care companions reported to facility that R1 becomes agitated and combative in the evening due to sundowning. Physician report dated 04/01/2021 indicates a diagnosis of Mild Cognitive Impairment with a notation of progressive cognitive decline.

During the visit, LPA toured the facility as well as interviewed R1, residents, and care companion for R1. R1 appears clean and well taken care of. R1 verbalized feeling safe at the facility.





No citations noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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