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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003905
Report Date: 12/20/2023
Date Signed: 12/20/2023 11:30:26 AM

Document Has Been Signed on 12/20/2023 11:30 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AEGIS ASSISTED LIVING OF LAGUNA NIGUELFACILITY NUMBER:
306003905
ADMINISTRATOR:ERIC MEDORFACILITY TYPE:
740
ADDRESS:32170 NIGUEL ROADTELEPHONE:
(949) 496-8080
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 96CENSUS: 58DATE:
12/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Kurt KnauerTIME COMPLETED:
11:45 AM
NARRATIVE
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This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 11/27/23 regarding Resident #1 (R1). LPA met with Administrator (AD) Kurt Knauer and discussed the purpose of the inspection.

During the inspection, LPA and AD toured the facility and inspected R1’s room. LPA conducted health and safety checks on residents present and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations, the electricity and water were running, the facility had soap and paper towels, and the medications, sharps, and toxins were properly stored. LPA interviewed AD and staff and requested and reviewed copies of R1’s resident file. LPA and AD observed the following: R1’s most recent Physician’s Report was completed on 06/10/22 and states R1 has Dementia.

Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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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Document Has Been Signed on 12/20/2023 11:30 AM - It Cannot Be Edited


Created By: Sean Haddad On 12/20/2023 at 11:07 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AEGIS ASSISTED LIVING OF LAGUNA NIGUEL
FACILITY NUMBER: 306003905

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2024
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment… This requirement was not met as evidenced by:
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Licensee stated they will ensure all residents with Dementia have Physician's Reports completed within the last year and will submit proof to LPA by POC due date.
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Based on documents, the licensee did not ensure R1 received an annual medical assessment when R1’s last medical assessment was conducted on 06/10/22, which poses a potential health risk to persons in care.
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Licensee stated they have a protocol for obtaining annual Physician's Reports for residents with Dementia and will submit a copy to LPA by POC due date.

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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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023


LIC809 (FAS) - (06/04)
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