374602653-10-11-2022-08-AS-IESA-CKAPQ7-20221017113039

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374602653
Report Date: 10/07/2022
Date Signed: 10/11/2022 09:08:57 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2021 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20210712084113

FACILITY NAME:	AEGIS ASSISTED LIVING AT SHADOWRIDGE		FACILITY NUMBER:	374602653
ADMINISTRATOR:	PHILLIPS, PARRISH E.		FACILITY TYPE:	740
ADDRESS:	1440 SOUTH MELROSE DRIVE		TELEPHONE:	(760) 806-3600
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92056
CAPACITY:	95	CENSUS: 63	DATE:	10/07/2022
		UNANNOUNCED	TIME BEGAN:	01:56 PM
MET WITH:	Elizabet Jones, Health Services Director		TIME COMPLETED:	02:27 PM

ALLEGATION(S):

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Facility neglect and/or lack of supervision resulted in the questionable death of a resident in care

INVESTIGATION FINDINGS:

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On 10/7/2022, at approximately 1:56 PM, Licensing Program Analyst (LPA) Daniel Pena, conducted an unannounced visit to the facility to conclude a complaint investigation. LPA was met at the entrance by Health Services Director, Elizabet Jones. After identifying himself and displaying his department identification, LPA was allowed inside the facility. LPA met with Director Jones to whom the elements of the complaint were discussed.

It was alleged that facility neglect and/or lack of supervision resulted in the questionable death of a resident in care [Resident 1-R1]. The Department’s investigation consisted of facility visits, facility and outside source record reviews, and interviews with staff, residents and R1’s responsible person.

Records indicate that the facility sent an unusual incident with injury report to CCLD on 7/14/2021. Per the report, on 7/8/21 at about 7:45 PM, R1 was observed lying on the ground in the common area living room. R1 was positioned in front of their wheelchair. Staff observed a bump on the left side of R1’s head. R1 was non-verbal and could not communicate with staff. Staff called 9-1-1 and R1 was transported to

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210712084113

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AEGIS ASSISTED LIVING AT SHADOWRIDGE	FACILITY NUMBER: 374602653
	VISIT DATE: 10/07/2022

NARRATIVE

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the Emergency Department via ambulance for evaluation and treatment.

Medical records reviewed included a computerized imaging scan of R1’s neck. Per the Medical Examiner’s reporting, the scan showed a closed displaced fracture of the posterior arch of the first cervical vertebra. R1 was admitted to the hospital but not considered for surgical fixation. On 7/10/2021, R1 was transferred to another hospital for continued care. R1 was admitted but given a poor prognosis. R1’s responsible person elected to transition R1 to comfort care measures. Treatment was withdrawn and death was confirmed on 7/13/2021 at 7:25 AM. The Medical Examiner’s report listed the cause of R1’s death as complications of cervical spine fracture due to blunt force injury of head and neck.

R1 was admitted to Aegis Assisted Living on 11/8/2018. Records indicate R1’s primary diagnosis was cerebral atherosclerosis. R1’s secondary diagnoses included coronary artery bypass graft, chronic kidney disease, hyperlipidemia, hypertension and hypothyroidism. R1 also had a diagnosis for dementia, was non-ambulatory, incontinent and required assistance with all activities of daily living (ADL). It should be noted that R1 was wheelchair bound. R1’s needs and assessment report, dated 5/25/21, noted that R1 had a potential for falls and required observation from staff for safety. The record also shows that R1 was a two-person transfer. Generally speaking, facilities are not required to provide one-to-one supervision unless specifically stated.

Interviews revealed that no staff or resident witnessed R1 fall from their wheelchair. Staff working in the area heard a sound like a body hitting the ground. Once they saw R1 on the floor they responded to assist, including calling 9-1-1 for emergency medical services. Staff denied leaving R1 unsupervised and said they were likely tending to another resident when the incident occurred. Normally, line of sight supervision of residents is not required. Staff, generally, positions themselves in the immediate area so they are able to perform resident supervision and provide assistance as needed. Investigative tours showed that the facility does not have a Closed-Circuit Television (CCTV) system so no visual recall of the incident was available. Interviews disclosed that a resident was observed near R1 in the common area at the time of the incident. Interviews with residents and staff did not bring forward evidence suggesting that the resident was involved in R1’s fall.

The Department has investigated the allegation that facility neglect and/or lack of supervision resulted in the questionable death of a resident in care. Based on the information obtained during the course of this

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210712084113

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: AEGIS ASSISTED LIVING AT SHADOWRIDGE	FACILITY NUMBER: 374602653
	VISIT DATE: 10/07/2022

NARRATIVE

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investigation, insufficient evidence was obtained to support the allegation. Therefore, the finding is determined to be Unsubstantiated. Although the allegation may have occurred or could be valid, there is not a preponderance of evidence to prove it occurred.

An exit interview was conducted with Director Jones and a copy of this report along with Licensee/Appeal Rights (LIC 9058 01/16) were provided and Director Jones' signature on this form confirms receipt of these reports.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC9099 (FAS) - (06/04)

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