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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602653
Report Date: 07/10/2023
Date Signed: 07/10/2023 05:29:21 PM


Document Has Been Signed on 07/10/2023 05:29 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, 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: 67DATE:
07/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:General Manager Charles Bloom and Health and Wellness Director Dustin BanksTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with General Manager Charles Bloom and Health and Wellness Director Dustin Banks.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received 03/27/2023). The LIC624 described an as-needed (PRN) medication incident occurring on the evening of 03/16/2023, involving Staff #1 (S1) and Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. The medication incident did not result in any adverse symptoms for R1.

During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were safe. LPA also reviewed pertinent care records and interviewed relevant staff.

Based on specific details and context surrounding the incident, no deficiency was issued.

Also, no deficiencies were observed or cited during today’s visit.

An exit interview was conducted with Bloom and Banks, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
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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