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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602653
Report Date: 10/20/2022
Date Signed: 10/20/2022 04:46:55 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/21/2022 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20220421141703
FACILITY NAME:AEGIS ASSISTED LIVING AT SHADOWRIDGEFACILITY NUMBER:
374602653
ADMINISTRATOR:WOLFGANG JONASFACILITY TYPE:
740
ADDRESS:1440 SOUTH MELROSE DRIVETELEPHONE:
(760) 806-3600
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:95CENSUS: 60DATE:
10/20/2022
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Charles BloomTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Licensee did not observe resident's change in condition resulting in hospitalization and severe sepsis
Licensee did not meet toileting needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint investigation visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Charles Bloom.

The Department’s investigation consisted of interviews with staff, residents, and outside sources, review of records, and a tour of the facility. It was alleged that the Licensee did not meet toileting needs and that the Licensee did not observe resident’s change in condition resulting in hospitalization and severe sepsis. Interviews with staff and outside sources revealed that when Resident 1 (R1) was admitted to the facility, R1 was non-ambulatory, needed assistance with bathing, dressing, grooming, and toileting, and had a minor memory impairment. Interviews with the staff revealed that around 12/27/2021, staff observed R1 confused, lethargic, and did not want to eat but was not in distress. Staff notified R1’s son and he drove R1 to the hospital.
Continued on LIC9099-C page.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 08-AS-20220421141703
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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Interviews with R1’s physician and review of medical records revealed that R1 was treated for a urinary tract infection (UTI), sepsis, and kidney problems. During R1’s hospitalization, R1 had a foley catheter inserted. R1 was discharged back to the facility after a stay in a skilled nursing facility (SNF) on 1/11/2022. Interviews with staff and outside sources revealed that staff used a device called a Hat device which is placed in the toilet to check a resident’s urine output, ensure residents are consuming enough fluids, and to collect urine for medical samples. R1’s physician stated that R1 had a history of UTIs and sepsis and R1 retained urine and was not able to fully empty their bladder which increased R1’s chances of getting a UTI. R1’s physician stated that it is common for symptoms of UTI to not appear until the infection worsens.

On 1/27/2022, staff assisted R1 to the toilet and observed R1 with a prolapsed organ. R1 was transported to the hospital where R1 received surgery for a prolapsed rectum which resulted in a colostomy bag. R1 was discharged back to the facility on 2/16/2022. Interviews revealed that R1 was a private individual and preferred for staff to assist R1 to the toilet and leave R1 on the toilet until R1 used their pendant to call staff when R1 was finished using the toilet. Interviews with staff revealed that R1 would sometimes sit on the toilet for 20-30 minutes but staff would check on R1 after about 15-20 minutes if R1 had not called for assistance. Interviews with R1 revealed that R1 was happy with the care provided by staff and there were a few occasions where R1 felt like staff had left R1 on the toilet for too long. R1 stated that those occasions were due to staff being busy with other residents. Interviews with residents revealed that they felt comfortable and happy with the care provided by staff and while staff were busy, they would respond promptly when residents needed assistance. Interviews with outside sources revealed staff were attentive to resident requests. Interviews with R1’s physician revealed that being left on the toilet for too long could not directly be attributed to R1’s prolapsed rectum. R1’s physician stated that R1 had occasional constipation and pushing when having a bowel movement could contribute to a prolapsed rectum. R1’s physician stated that a prolapsed rectum can occur suddenly or over time, but would be painful and R1 would have complained about pain if it had occurred over time.

The Department has investigated the above-mentioned allegations and based on interviews and record review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/21/2022 and conducted by Evaluator Rebecca A Ruiz
COMPLAINT CONTROL NUMBER: 08-AS-20220421141703

FACILITY NAME:AEGIS ASSISTED LIVING AT SHADOWRIDGEFACILITY NUMBER:
374602653
ADMINISTRATOR:WOLFGANG JONASFACILITY TYPE:
740
ADDRESS:1440 SOUTH MELROSE DRIVETELEPHONE:
(760) 806-3600
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:95CENSUS: 60DATE:
10/20/2022
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Charles BloomTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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9
Unlawful Eviction
Licensee did not provide a written notice of rate increase
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint investigation visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Charles Bloom.

The Department’s investigation consisted of observations, interviews with staff, residents, and outside sources, review of records, and a tour of the facility. It was alleged that the Licensee did not provide a written notice of rate increase. Interviews with staff revealed that residents were reassessed every 90 days or whenever a change in condition was observed. Residents’ responsible parties were informed either by written notice or verbally. Interviews with staff revealed that R1’s responsible party preferred to be notified of R1’s changes in level of care verbally. Review of R1’s medical assessment dated 9/10/2021 revealed that R1 was intermittently incontinent and required assistance with bathing, grooming, dressing, and toileting.

Continued on LIC9099-C page.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20220421141703
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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Review of facility care assessments dated 1/11/2022 and 09/07/2021 revealed that R1 had been reassessed and R1’s care needs and costs increased. Both care assessments were not signed by R1 or R1’s responsible party and did not have any documentation that either R1 or their responsible party were notified of the care increase. Review of facility care assessment dated 10/01/2021 revealed that R1 had been reassessed and R1’s care needs and costs increased. This assessment was not signed by R1 or R1’s responsible party. The assessment included a statement that R1’s family was notified of the care increase.

It was alleged that the Licensee unlawfully evicted R1. Witness interviews revealed that on 2/15/2022, R1 was discharged from the hospital and was transported back to the facility. Interviews revealed that because R1 was being discharged back to the facility after hours, the facility would not accept R1 back at that time and R1 was sent back to the hospital. R1 was able to return to the facility the next day, on 2/16/2022. Interviews with staff did not disclose that R1 was returned to the hospital on 2/15/2022.

The Department has investigated the above-mentioned allegations and based on interviews and record review, the preponderance of the evidence have been met, therefore, these allegations are deemed substantiated. The following deficiencies were cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20220421141703
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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)
Type B
11/11/2022
Section Cited
HSC
1569.657(a)
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1569.657(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident's representative, if any, written notice of the rate increase within two business days after initially providing services...
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Executive Director agrees to meet with R1's family to review care increases and refund any additional care fees that were not approved by the responsible party. Licensee will send LPA a copy of the letter sent to the family addressing the care increase refunds by POC due date.
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This requirement has not been met as evidenced by:
Based on interviews and record review, the Licensee did not provide the resident and resident’s responsible party with a written notice of rate increase. This posed a potential personal rights risk to R1.
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Type B
11/22/2022
Section Cited
CCR
87468.2(a)(20)
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87468.2 Personal Rights of Residents in Privately Operated Facilities (a)(20) to be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations and shall comply with all eviction and relocation protections for residents.
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Licensee agrees to review re-admission policy and conduct an in-service training with staff regarding accepting residents back from outside care. Licensee will provide LPA with the sign in sheet for inservice training by POC due date.
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This requirement has not been met as evidenced by: Based on interviews and records review, the Licensee did not ensure the resident was protected from eviction when R1 was not accepted back to the facility. This posed a personal rights risk to R1.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5