306005948-5-5-2022-22-AS-KLYN-CE5SF3-20220505134941

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005948
Report Date: 05/05/2022
Date Signed: 05/05/2022 01:49:47 PM

Document Has Been Signed on 05/05/2022 01:49 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	AEGIS LIVING DANA POINT		FACILITY NUMBER:	306005948
ADMINISTRATOR:	NAZARETH, SHEILA		FACILITY TYPE:	740
ADDRESS:	26922 CAMINO DE ESTRELLA		TELEPHONE:	(949) 488-2650
CITY:	DANA POINT	STATE: CA	ZIP CODE:	92624
CAPACITY: 76		CENSUS: 86	DATE:	05/05/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Eric Medor		TIME COMPLETED:	02:10 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	Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on an incident report received by Community Care Licensing (CCL) on 05/03/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit. Executive Director Eric Medor was present during the visit. Incident report dated 05/03/2022 indicated R1 was observed by staff outside the facility approximately .3 miles down the street. Resident was escorted back to the facility and was assessed to have no injuries. Administrator indicates resident was observed by staff walking down the hall inside facility and stated to the staff that the resident was going to an appointment. Staff advised the resident that there was not an appointment and R1 stated the resident would return to the resident's room. Staff continued on with tasks. Five to ten minutes later the staff realized the resident had not returned to the room. Facility staff started looking for resident inside and outside the facility. At this time facility driver observed the resident up the street. Administrator indicates there were no staff at the front desk when the resident left as front desk staff do not come on shift until 8 AM. Administrator exploring options for earlier staff at front desk and resident was outfitted with a wander guard on resident's person and walker. Resident was been at the facility since January 2022. Physician report dated 01/28/2022 indicates R1 is unable to leave the facility unassisted. LPA met with R1 during the visit. Resident appears clean and well taken care. Resident verbalized feeling safe at the facility. Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

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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Document Has Been Signed on 05/05/2022 01:49 PM - It Cannot Be Edited

Created By: Kimberly Lyman On 05/05/2022 at 01:37 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 LIVING DANA POINT	FACILITY NUMBER: 306005948
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/06/2022 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not being met as evidenced by:	1 2 3 4 5 6 7	Licensee to provide elopement re-training to staff and forward proof to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, Licensee failed to ensure R1 was provided care and supervision. R1 eloped out of the facility and was discovered approximately .3 miles down the street. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

Alisa Ortiz

LICENSING EVALUATOR NAME:

Kimberly Lyman

LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

LIC809 (FAS) - (06/04)

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