<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005948
Report Date: 06/14/2022
Date Signed: 06/14/2022 02:37:33 PM


Document Has Been Signed on 06/14/2022 02:37 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 LIVING DANA POINTFACILITY NUMBER:
306005948
ADMINISTRATOR:NAZARETH, SHEILAFACILITY TYPE:
740
ADDRESS:26922 CAMINO DE ESTRELLATELEPHONE:
(949) 488-2650
CITY:DANA POINTSTATE: CAZIP CODE:
92624
CAPACITY:76CENSUS: 53DATE:
06/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Eric Medor and Sheila NazarethTIME COMPLETED:
02:55 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 unannounced case management visit to follow up on an incident report received by Community Care Licensing (CCL) on 06/03/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit. Executive Director Eric Medor and Health Services Director Sheila Nazareth were present during the visit.

Incident report dated 06/06/2022 indicated Resident 1 (R1) was heard by staff to be calling for help. Staff responded and the resident was found on the floor. Resident stated that the resident had fell and was complaining of back pain. 911 was called and resident was transferred out. R1 was diagnosed with a closed fracture of the 11th thoracic vertebrae. R1 was transferred back to the facility with pain management and no further intervention required. Urinalysis conducted on resident indicated a positive result for urinary tract infection. Resident tested positive for covid on 06/13/2022 and is currently on quarantine with a care companion.

Physician report dated 07/01/2021 indicated a diagnosis of Dementia with intermittent confusion. Service assessment dated 05/02/2022 indicates episodes of unsteady gait with vertigo however did not require assistance with transfers or additional status checks. Facility states resident was on two hour checks, wore a pendant, and was on escorts. R1 had a prior fall on 01/13/2022.



No deficiencies 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: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1