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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005474
Report Date: 08/21/2025
Date Signed: 08/21/2025 05:01:00 PM

Document Has Been Signed on 08/21/2025 05:01 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AEGIS RESIDENTIAL LIVINGFACILITY NUMBER:
306005474
ADMINISTRATOR/
DIRECTOR:		SALVADOR DIAZFACILITY TYPE:
740
ADDRESS:24371 AUGUSTINTELEPHONE:
(949) 683-6927
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
08/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Jennifer Perez- AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Required 1-Year annual evaluation using the Care Inspection Tool. LPA was greeted and granted entry by Administrator (Admin) Jennifer Perez and explained the reason for the visit. Administrator provided proof of administrator's course work which completed on June 25, 2025.

The facility is a single story structure and is licensed to provide services for age range 60 and over for six non-ambulatory residents. A waiver was granted to provide hospice services to two residents at one time. During today's visit, there are six residents in care of which one is under hospice and two staff on duty.

LPA toured the physical plant with Admin Perez. Facility is clean and sanitary. LPA observed four resident bedrooms and two resident bathrooms. Resident bedrooms had all required furnishings. Bathrooms were found to be in compliance, clean, and operational. The hot water temperature measured at 108.6 and 107.4 degrees Fahrenheit in the resident bathrooms. All common areas were inspected including the detached two car garage. The swimming pool gate is secured and the fire place is properly screened. LPA reviewed the Emergency Disaster Plan (LIC610E) and observed sufficient emergency food and water in the garage. The 610E was not reviewed annually and the emergency drills were not conducted quarterly. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction, the exit gates are operational, and there were sufficient seating and shading.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/21/2025 05:01 PM - It Cannot Be Edited


Created By: Jessica Cho On 08/21/2025 at 04:00 PM
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 RESIDENTIAL LIVING
FACILITY NUMBER: 306005474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of two staff on duty which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2025
Plan of Correction
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Admin stated that CPR/First Aid training will be completed and proof of certificates will be submitted to LPA by POC due date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in five out of six residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2025
Plan of Correction
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Admin stated that the reappraisals will be submitted to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Jessica Cho
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/21/2025 05:01 PM - It Cannot Be Edited


Created By: Jessica Cho On 08/21/2025 at 04:11 PM
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 RESIDENTIAL LIVING
FACILITY NUMBER: 306005474

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(2)
87465 Incidental Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two out of six residents, R1 and R4, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2025
Plan of Correction
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Admin stated that proof of an in-service training covering medications for all staff as well as an Acknolwedgement of Understanding of the said deficiency will be submitted to LPA by POC due date.
Type B
Section Cited
CCR
1569.625(b)(2)
1569.625(b)(2) ...training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in two out of two staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2025
Plan of Correction
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Admin stated that proof of the trainings will be submitted to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Jessica Cho
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AEGIS RESIDENTIAL LIVING
FACILITY NUMBER: 306005474
VISIT DATE: 08/21/2025
NARRATIVE
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The fire extinguisher was purchased on August 21, 2025 as verified per the purchase receipt. The auditory devices and smoke/carbon monoxide detectors were tested and operational. The Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the correct size.

LPA conducted a review of all resident/staff files. Discrepancy noted with resident files as five out of six residents did not have a current reappraisal. Two out of two staff are not CPR/First Aid certified and did not complete their annual 20 hour training for this year. Medications were audited in six out out of six residents. Discrepancies noted in two out of six residents as medications were not administered as prescribed. An interview was conducted with one resident due to insufficient time.

LPA discussed the following areas: to ensure reappraisals for all residents are completed as frequently as necessary or annually, medications are administered as prescribed, to ensure at least one staff per shift is CPR/First Aid certified, to ensure staff are receiving their 20 hour annual training, to conduct quarterly emergency drills per shift, to review the LIC610E annually and update as necessary, and to ensure timely payments of the annual licensing fee due on August 24, 2025.

Based on the observations made during today's visit, deficiencies are being cited, and Technical Violations are also being issued.

An exit interview was conducted with Administrator Jennifer Perez, and a copy of this report was provided at exit.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC809 (FAS) - (06/04)
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