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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005474
Report Date: 08/02/2022
Date Signed: 08/02/2022 12:52:27 PM


Document Has Been Signed on 08/02/2022 12:52 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 RESIDENTIAL LIVINGFACILITY NUMBER:
306005474
ADMINISTRATOR:SALVADOR DIAZFACILITY TYPE:
740
ADDRESS:24371 AUGUSTINTELEPHONE:
(949) 683-6927
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Administrator Salvador Diaz TIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection to this facility. LPA met with Administrator (AD) Salvador Diaz and stated the purpose of this visit.

This facility is a single level structure and licensed for 6 non-ambulatory and with hospice waiver for two. On this visit, no resident was under hospice care.

About 11:44 AM, LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. LPAs toured the interior and exterior portions of the facility. LPA observed four residents in care and two staff members on the floor. There were three private and one shared resident's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were provided with handrails; and water fixtures were observed to be in good repair. Hot water was measured at 120 degrees Fahrenheit. Medications, cleaning supplies and sharp kitchen items were inaccessible to residents in care. Facility met the minimum 2 day perishable and 7 day non perishable food stock requirements. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair. Pool was enclosed by permanent steel fence and rendered inaccessible to residents in care. Grounds were free of tripping hazards. Side exit doors were self latching and self closing. LPA reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. LPA also discussed the California Code of Regulations (CCR) Section 87470 Infection Control Requirements. AD was informed to send all incident reports and general correspondence to CCLASCPOrangeCountyRO@dss.ca.gov

No citation was issued for this visit.

LPA Marin conducted an exit interview with AD Sal Diaz and copy of this report and informational materials from California Department of Public Health regarding COVID 19 vaccination were left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
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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