374602653-10-20-2022-08-AS-RARZ-CKE2AA-20221020171313

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602653
Report Date: 10/20/2022
Date Signed: 10/20/2022 05:13:19 PM

Document Has Been Signed on 10/20/2022 05:13 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	CENSUS: 60	DATE:	10/20/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	04:55 PM
MET WITH:	Charles Bloom		TIME COMPLETED:	05:15 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 Rebecca Ruiz met with Executive Director Charles Bloom for a Case Management visit to follow-up on a substantiated allegation of staff did not seek medical attention for a resident. On February 28, 2022, the Department received a complaint alleging staff did not seek medical attention for a resident (R1). The Department conducted an investigation which revealed on February 25, 2022, at 5:15 a.m. S1 found R1 on the floor, but S1 left R1 unattended on the floor without conducting an assessment or calling for assistance reportedly due to her behavior. Based on staff interviews, at approximately 7:00 a.m., Staff 2 (S2) found R1 on the floor. S2 radioed S1 and Staff 3 (S3) and they assisted by changing R1’s soiled clothing and placing R1 back into bed. The incident was reported to Staff 4 (S4), the facility’s LVN, who confirmed during an interview that an assessment was done on R1 and no injuries were observed. On the evening of February 25, 2022, at approximately 9:25 p.m., Staff 5 (S5) observed R1 with bruises on their face and reported them to S4 via text message photos. Per staff interviews, on February 26, 2022, at approximately 8:30 a.m. S4 returned to the facility and observed R1 hunched over holding their left side, grimacing, and with bruising on the nose. S4 reported that that 911 was contacted at 11:30 a.m. but the local fire department doesn’t have a record of the call. On February 26, 2022 at approximately 12:45 p.m. R1’s responsible party arrived after receiving notification at approximately 11:45 a.m. After observing R1’s condition, R1’s responsible party requested emergency medical services. Subsequently, the local fire department transported R1 to the hospital. Hospital records show R1 was triaged in the emergency room at 2:07 p.m. and was admitted to the hospital for inpatient treatment at 7:05 p.m. Continued on LIC809-C page.

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

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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R1 was diagnosed with a status post mechanical fall, including a minimally displaced right sixth and seventh rib fracture, blunt head trauma, acute nose contusion, acute right flank pain, and acute left hip pain. R1 was hospitalized for approximately 36 hours, from February 26, 2022, to February 28, 2022, and was discharged to a Skilled Nursing Facility.

On September 29, 2022, substantiated findings were delivered by the Department regarding the allegation that “staff did not seek medical attention for resident,” and the licensee was cited for violating the California Code of Regulations, Title 22, Section 87465(a)(1), Incidental Medical and Dental Care, for not arranging, or assisting to arrange medical care appropriate to the conditions and needs of R1. An immediate civil penalty of $500.00 was assessed as a result of this violation and the licensee was advised that an additional civil penalty may be assessed based on H&S Code § 1569.49.

The Department has concluded an analysis and has determined that an additional civil penalty is warranted for a violation that resulted in R1 sustaining serious bodily injuries while under the care of this facility. Welfare and Institutions Code § 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 not seeking medical assistance causing serious bodily injury resulting in the resident’s hospitalization from February 26, 2022 to February 28, 2022 and the need for a higher level of care.

Today, October 20, 2022, the Department is issuing a civil penalty per H&S Code § 1569.49(f), in the amount of $10,000.00 for a violation that the Department constitutes as serious bodily injury. However, since an immediate civil penalty of $500.00 was previously issued on September 29, 2022, the amount of the civil penalty issued is reduced to $9,500.00.

A copy of the LIC421D was given to Executive Director Charles Bloom and originals were signed.

An exit interview was conducted, and a copy of this report, along with the licensee’s Appeal Rights, was provided to Charles Bloom. Charles Bloom's signature on this report, acknowledges receipt of the Appeal Rights, found on page two of the LIC421D.

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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