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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003905
Report Date: 12/16/2022
Date Signed: 12/16/2022 01:29:12 PM


Document Has Been Signed on 12/16/2022 01:29 PM - It Cannot Be Edited

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 LAGUNA NIGUELFACILITY NUMBER:
306003905
ADMINISTRATOR:ERIC MEDORFACILITY TYPE:
740
ADDRESS:32170 NIGUEL ROADTELEPHONE:
(949) 496-8080
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:96CENSUS: 86DATE:
12/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Karen AshleyTIME COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA was screened for Covid-19 and granted entry. LPA met with Health Services Director. Karen Ashley. LPA explained the reason for the visit. The Agency (CCL) received a unusual incident report (LIC 624) on 12/09/22 which reported that Resident 1 (R1) had an unwitnessed fall on 12/4/22. Facility staff contacted the Hospice nurse. The Hospice Nurse examined R1 and called 911 to have them transferred to Mission Hospital. The responsible party for R! and the primary care physician (PCP) were notified. Resident was treated at the hospital and released on 12/9/22. R1 has a 1 on 1 care provider at this time and has been put on alert charting for 3 days. Staff reported that R1's service plan will be updated. R1 has returned to the facility. LPA observed R1 in their room. R1 reported no issues. LPA reviewed R1's physician's report (LIC 602A) and hospital discharge paperwork. LPA consulted with the Health Services Director concerning staff training, visiting guidelines and reporting requirements. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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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