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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005948
Report Date: 12/22/2022
Date Signed: 12/22/2022 03:15:01 PM


Document Has Been Signed on 12/22/2022 03:15 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: 66DATE:
12/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Eric MedorTIME COMPLETED:
02:33 PM
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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 11/21/2022. LPA was greeted and granted entry into the facility by Executive Director Eric Medor and explained the reason for the visit.

Incident report dated 11/15/2022 indicated a fall alert for Resident 1 (R1) and staff responded. R1 stated falling while using the restroom. R1 was transferred out with a fracture of the left hip, non-operable. Resident was transferred to a skilled nursing and returned to facility on 12/01/2022. Resident returned on hospice due to decline. Physician report dated 01/10/2022 indicated resident was independent with no mental decline. Re-assessment on 11/28/2022 indicated a diagnosis of Dementia. LPA met with R1 and R1's son during the visit. Both verbalized satisfaction with facility services and caregiving. R1 has had a 24 hour care companion since returning to the facility. No falls or issues since return.








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: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022
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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