374602653-10-20-2022-08-AS-RARZ-CKE2MV-20221020173146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602653
Report Date: 10/20/2022
Date Signed: 10/20/2022 05:31:59 PM

Document Has Been Signed on 10/20/2022 05:31 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 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	TOTAL ENROLLED CHILDREN: 0	CENSUS: 60	DATE:	10/20/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	05:15 PM
MET WITH:	Charles Bloom		TIME COMPLETED:	05:35 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	On October 20, 2022, Licensing Program Analyst (LPA) Rebecca Ruiz met with Charles Bloom for a Case Management visit to follow-up on a substantiated allegation that facility did not protect resident. On April 16, 2019, the Department received a complaint alleging “facility failed to protect resident”. The Department conducted an investigation and determined that resident (R1) resided in the “memory care” unit in the facility. On March 31, 2019 around 8:00 p.m., R1 exited the memory care unit through an unlocked side door which led to an outside terrace area. Per staff interviews, staff was unaware that R1 wasn’t in the memory care unit until approximately 9:00 p.m. At 9:55 p.m., R1 was found lying face down on the ground in the outdoor patio. R1 was semi-conscious and observed as having dirt in their mouth and dried blood on their arms, along with extensive scratches and bruising. Hospital records confirmed R1 was diagnosed upon admission with dehydration, a closed left lateral rib fracture, a displaced left middle finger fracture, contusions of both the left and right knee, and lacerations of the left wrist. R1 was hospitalized from March 31 to April 2, 2019. On December 20, 2019, the Department substantiated the allegation that the “Facility failed to protect resident” and the licensee was cited for violating the California Code of Regulations Title 22 (22 CCR), § 87705(j) Care of Persons with Dementia, which states, “The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.” The licensee did not protect R1 by not having a functional auditory device, which resulted in elopement, serious bodily injury, and posed an immediate safety risk to a resident in care. The licensee was informed that a civil penalty was still being determined and may be assessed based on Health and Safety (HSC) §1569.49. Continued on LIC809-C page.

Lizzette Tellez	TELEPHONE: (619) 767-2351
Rebecca A Ruiz	TELEPHONE: (619) 318-7620
	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 SHADOWRIDGE	FACILITY NUMBER: 374602653
	VISIT DATE: 10/20/2022

NARRATIVE

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The Department has concluded an analysis and has determined that a civil penalty per HSC §1569.49(f), in the amount of $10,000 is warranted for a violation that resulted in R1 sustaining serious bodily injuries while under the care of this facility. Welfare and Institutions Code (WIC) §15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery or physical rehabilitation.”

This is evidenced by the licensee’s failure to ensure proper care and supervision for R1, resulting in R1 sustaining multiple fractures which required hospitalization.

Today October 20, 2022, the Department is issuing an additional citation per 22 CCR § 87464 Basic Services.

A copy of the LIC 421D form was given to Charles Bloom and originals were signed.

An exit interview was conducted, a copy of this report was issued, and Appeal Rights were provided. Charles Bloom's signature on this report acknowledges receipt of the Appeal Rights, found on page two of the LIC 421D form.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/20/2022 05:31 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 SHADOWRIDGE	FACILITY NUMBER: 374602653
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 10/21/2022 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).	1 2 3 4 5 6 7	Licensee agrees to schedule outside vendor training for staff on supervision and will notify the Department in writing by POC due date 10/21/2022. Licensee agrees to provide the Department with a copy of the training and sign in sheet once completed.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not provide supervision as defined by Section 87101(c)(3) and HSC 1569.2(c) in 1 of 60 persons in care [R1] which posed an immediate Health, Safety, and Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Lizzette Tellez	TELEPHONE: (619) 767-2351
Rebecca A Ruiz	TELEPHONE: (619) 318-7620
	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC809 (FAS) - (06/04)

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