374602653-5-13-2024-08-AS-RARZ-D58RHC-20240513130207

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602653
Report Date: 05/13/2024
Date Signed: 05/13/2024 01:02:11 PM

Document Has Been Signed on 05/13/2024 01:02 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	AEGIS ASSISTED LIVING AT SHADOWRIDGE		FACILITY NUMBER:	374602653
ADMINISTRATOR:	LANCE SHENK		FACILITY TYPE:	740
ADDRESS:	1440 SOUTH MELROSE DRIVE		TELEPHONE:	(760) 806-3600
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92056
CAPACITY:	95	CENSUS: 65	DATE:	05/13/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Health Services Director Claire Molina		TIME COMPLETED:	11:30 AM

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) Rebecca Ruiz conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Health Services Director (HSD) Claire Molina. LPA spoke with General Manager Charles Bloom on the phone. During today's visit, LPA observed residents in care, conducted a health and safety check, reviewed records, and interviewed staff and residents. The purpose of today's visit was to conduct follow up regarding a self-reported incident. On 5/6/2024, the Department received an incident report from the facility describing an incident that occurred on 4/25/2024, where Resident 1 (R1) fell in their bathroom at approximately 7:30pm and was discovered by Staff 1 (S1) the following morning at around 8:00am on 4/26/2024. [HSD was provided with an LIC811 Confidential Names List to identify individuals]. Interviews and review of R1's assessment records prior to the incident on 4/25/2024, revealed that R1 was independent of all care and did not require any assistance or status checks. Interviews and review of call buttons for the night of 4/25 and morning of 4/26 revealed that R1's call button in the bathroom was malfunctioning and did not register a call from R1's room into the facility's electronic system. Additionally, R1 was not wearing their personal call pendant during the incident. Interviews with S1 and R1 confirmed the narrative described in the incident report. HSD stated that call pendants have a fall detection software and R1 has a motion sensor system in their bedroom, however since R1 was not wearing their pendant and did not fall in the bedroom, both systems were not alerted. Interviews with staff and R1 revealed that facility staff contacted paramedics upon discovering R1 on the floor and R1 received medical attention and returned to the facility on 4/26/2024 with no injuries. Continued on LIC809-C page...

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AEGIS ASSISTED LIVING AT SHADOWRIDGE	FACILITY NUMBER: 374602653
	VISIT DATE: 05/13/2024

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HSD stated that since the incident, all residents' call buttons have been checked to ensure they are working correctly, staff have been provided an in-service training to check on all residents during their shift and track if residents are not attending meals, and R1 has been provided with reminders to wear their call pendant at all times.

No deficiencies were cited in relation to this incident. An exit interview was conducted with General Manager Charles Bloom via telephone and HSD Claire Molina, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

LIC809 (FAS) - (06/04)

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