306005474-8-12-2024-22-AS-KSGH-D83VS6-20240812164101

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005474
Report Date: 08/12/2024
Date Signed: 08/12/2024 04:42:09 PM

Document Has Been Signed on 08/12/2024 04:42 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	AEGIS RESIDENTIAL LIVING		FACILITY NUMBER:	306005474
ADMINISTRATOR:	SALVADOR DIAZ		FACILITY TYPE:	740
ADDRESS:	24371 AUGUSTIN		TELEPHONE:	(949) 683-6927
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	08/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Salvador Diaz, Licensee Jennifer Perez, Administrator		TIME COMPLETED:	05:00 PM

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	On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregivers after introducing himself and stating the reason of the visit. Licensee Salvador Diaz and administrator Jennifer Perez were notified by phone and arrived later to assist. During the inspection, LPA and facility staff conducted a tour of the physical plant and observed the following: The facility is a one story home with two private and two shared bedrooms and one staff room in addition to the facility's common living areas and two shared bathrooms. All resident bedrooms have the required furnishings. LPA observed all beds have linens and blankets. Postural supports observed in one room with corresponding physician orders verified to be on file. There are currently six residents admitted to the facility with two receiving hospice care. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets are operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. A fire and emergency drill was conducted in July 2024 along with an update of emergency supplies but was not documented at the time. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food. Smoke and carbon monoxide detectors tested operational. Fire extinguisher present are observed to be fully charged. There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on both sides of the house and routes of egress are free of obstructions. There is a pool present in the backyard with adequate fencing confirmed to be present. Residents are encouraged to use the pool under staff supervision. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

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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Document Has Been Signed on 08/12/2024 04:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AEGIS RESIDENTIAL LIVING	FACILITY NUMBER: 306005474
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above as one caregiver's ealth screening was found to be blank, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2024
	Plan of Correction
1 2 3 4	Licensee will update staff health screenings are provide documentation thereof to the Department before the plan of corrections due date.

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

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/12/2024 04:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AEGIS RESIDENTIAL LIVING	FACILITY NUMBER: 306005474
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(6)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above for one resident with dementia whose latest assessment was conducted in 2022. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2024
	Plan of Correction
1 2 3 4	Licensee will obtain an updated physician report and provide a copy to the Department before the plan of corrections due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AEGIS RESIDENTIAL LIVING	FACILITY NUMBER: 306005474
	VISIT DATE: 08/12/2024

NARRATIVE

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CONTINUED FROM FORM LIC809

Medication, sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed for accuracy during the visit. LPA reviewed six resident files and two staff files. One medical assessments for a resident with an indication of dementia were found to be outdated and will need an update. One staff health screening form is observed to be blank. Admission agreements signatures are incomplete in several forms and corrected during the visit.

Based on the observations made during today’s inspection, two type B deficiencies and seven advisory notes are being issued per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC809 (FAS) - (06/04)

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