306005948-6-3-2021-22-AS-KLYN-C3MQ9X-20210603115903

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005948
Report Date: 06/03/2021
Date Signed: 06/03/2021 03:38:24 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 LIVING DANA POINT		FACILITY NUMBER:	306005948
ADMINISTRATOR:	NAZARETH, SHEILA		FACILITY TYPE:	740
ADDRESS:	26922 CAMINO DE ESTRELLA		TELEPHONE:	(949) 488-2669
CITY:	DANA POINT	STATE: CA	ZIP CODE:	92624
CAPACITY:	76	CENSUS: 60	DATE:	06/03/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Joe Daldrup and Sheila Nazareth		TIME COMPLETED:	12:20 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	Licensing Program Analyst (LPA) Kimberly Lyman made an announced pre-licensing visit. LPA identified herself and discussed the purpose of the visit with Executive Director Joe Daldrup. An initial application to operate a Residential Facility Care for the Elderly was submitted to CCL on 11/30/2020 for a capacity of 66 non-ambulatory residents and 10 bedridden residents. There are 60 residents in care during today's visit. LPA observed facility is following covid precaution guidelines. LPA Lyman along with Executive Director Joe Daldrup, Administrator Sheila Nazareth, Health Services Director Caroline Kilby and Maintenance Director Geoff Rosecrans toured the facility at 9:30 AM and observed the following: Structure: Facility is a two story building housing 46 apartments in the assisted living and 19 apartments in the memory care unit. All assisted living apartments are currently single occupancy. Memory care unit has one apartment for double occupancy. Facility offers a library, beauty salon and bistro as well as two outside areas. Living Room/ Dining Room: Adequate seating is available in the main dining room and visiting areas. Bedrooms Residents: All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Rooms contain a mini kitchen area complete with a mini fridge. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. LPA pushed the emergency button in bathrooms observed and staff response was within ten minutes. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Facility has ample perishable and non perishable food supplies. All equipment is tested for temperature and are within acceptable ranges. LPA observed a posted menu with multiple choices for residents. The bistro has snack choices for residents. Smoke Detectors: Carbon monoxide detectors were tested operational. Smoke detectors are tested in-house and documentation was provided. Fire extinguishers are fully charged. Fire sprinklers are tested by an outside company and facility provided documentation of testing. Toxins: Secured and inaccessible to residents in care. Water Temperature: Tested and recorded between 105 and 107 degrees F in tested bathrooms. Emergency Supplies: LPA observed ample emergency food and water stored onsite at facility. Facility has a posted emergency menu in kitchen as well. CONT ON LIC 809C DATED 06/03/2021.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: AEGIS LIVING DANA POINT	FACILITY NUMBER: 306005948
	VISIT DATE: 06/03/2021

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LPA observed the emergency disaster plan and facility has submitted the mitigation plan as well.Medications, First-Aid Kit & Book: LPA observed multiple first aid kits and all contained required elements. Medications are stored in locked medication carts. Facility uses electronic medication administration record. Resident & Staff File: LPA reviewed staff and resident files during the visit. Reading Material, Games, and Equipment: LPA observed the activity room as well as posted activities in multiple locations. Outside areas: LPA observed two different outside shaded areas for residents, one in assisted living and one in memory care. Fire Clearance: Approved for 66 non-ambulatory residents and 10 bedridden residents on 03/24/2021. LPA observed the emergency chair adjacent to the staircase.

The facility is ready to be licensed. Component III not conducted during visit due to facility already being fully operational.

An exit interview was conducted with Executive Director and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC809 (FAS) - (06/04)

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