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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602653
Report Date: 11/18/2022
Date Signed: 11/18/2022 10:25:47 AM


Document Has Been Signed on 11/18/2022 10:25 AM - 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:AEGIS ASSISTED LIVING AT SHADOWRIDGEFACILITY NUMBER:
374602653
ADMINISTRATOR:LANCE SHENKFACILITY TYPE:
740
ADDRESS:1440 SOUTH MELROSE DRIVETELEPHONE:
(760) 806-3600
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:95CENSUS: 60DATE:
11/18/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Charles BloomTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted a plan of correction visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Executive Director Charles Bloom.

The purpose of the visit was to verify if the deficiency issues cited on October 20, 2022 had been corrected. On October 20, 2022, the licensee was issued a deficiency with a correction due date of November 11, 2022.

During today’s visit, LPA Ruiz was able to verify that the licensee corrected the deficiency regarding providing resident’s responsible party with written notice for rate increases due to changes in level of care. On November 1, 2022, the Executive Director had a conference with R1's responsible party. Therefore, the deficiency 1569.657(a) has been corrected.

An exit interview was conducted with Executive Director Charles Bloom and a copy of this report and the Licensee Rights (LIC9058 01/16) were provided via hardcopy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
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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