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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602653
Report Date: 10/20/2022
Date Signed: 10/20/2022 04:57:31 PM


Document Has Been Signed on 10/20/2022 04:57 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: 60DATE:
10/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Charles BloomTIME COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to provide an amended copy of an LIC9099. LPA was greeted by, identified herself to, and discussed the purpose of the visit with Executive Director Charles Bloom.

During today's visit, LPA obtained Executive Director's signature on the LIC9099 report dated 4/27/2022.

An exit interview was conducted with Executive Director Charles Bloom, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (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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