Aegis Assisted Living at Shadowridge

Allegation investigated: Staff did not treat residents with dignity

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Care Director Ron Puno. General Manager Charles Bloom arrived during the visit. During today’s visit, LPA observed residents in care and interviewed staff. The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that staff did not treat residents with dignity. Continued on LIC9099-C page... Substantiated Interviews with management revealed that there was a previous employee who was making multiple allegations regarding staff treatment of residents, restraining residents in wheelchairs with tables and walls, and not providing frequent incontinence care. Interviews with staff denied that the allegations occurred, stating that residents were frequently checked for any bruising, marks, or other injuries, and they would be reported right away if a resident sustained an injury. Staff denied that residents were handled in a rough manner or were rushed during care. Staff stated that residents were frequently checked for toileting and incontinence care and denied any issues with skin breakdown or other complications from soiled briefs. Interviews with staff denied the use of tables or walls as restraints for residents who used wheelchairs, and management stated that tables in the memory care are light enough to be pushed by residents if they wanted to get up from their wheelchair. Additionally, any residents who were deemed to be fall risks were kept in common areas where staff could monitor them. Interviews with residents and outside sources did not reveal any concerns regarding the quality of care provided by staff and denied any concerns regarding rough treatment, restraints, and protecting residents. Outside sources did state that there was occasionally an incontinence smell in the memory care, however, they also clarified it was due to residents having just soiled their briefs and not being left in soiled briefs for a very long time. The outside sources also stated that staff were very quick to respond to resident care needs. It was alleged that the facility did not submit an incident report regarding an altercation between two staff members while in the presence of residents. Review of employee discipline documents described the incident as a staff member used profanity towards another staff member while in the presence of residents. Interviews and review of the report did not provide any evidence that the profanity was directed towards residents. Interviews with facility management and review of incident reports submitted to the Department in 2023 revealed that the facility submitted incident reports for incidents regarding resident changes in conditions, falls, injuries, and hospitalizations. Review of regulatory requirements on incident reports revealed that incidents that threaten the safety, welfare, or health of residents are required. Review of the discipline document while paired with information collected during interviews did not reveal a regulatory requirement for the facility to submit an incident report to the Department. Continued on LIC9099-C page... Interviews with staff and management revealed that staff used a combination of online training, in person shadowing, and in-service training sessions. Interviews with staff revealed that staff completed online training and then shadowed during the first few weeks of employment. Interviews with staff revealed that ongoing online training classes were scheduled monthly and staff attended monthly staff meetings which covered multiple training topics. Management estimated that staff underwent between 30 and 40 hours of online training before shadowing for at least 24 hours before being released to provide resident care independently. Interviews with residents and outside sources did not reveal any concerns regarding the staff’s level and quality of training. Interviews with staff and facility management and review of staffing schedules in 2023 revealed that the facility scheduled an average of three caregivers and one medtech to cover the assisted living portion of the building and scheduled four caregivers to split the facility’s two memory care sections, with a medtech covering both sections during the AM and PM shifts. Staff stated that overnight supervision consisted of three caregivers covering assisted living, and each memory care section, and one medtech to cover any overnight medication needs. Interviews with staff, residents, and outside sources did not disclose any issues with residents receiving assistance with care. Additionally, some residents were brought out of memory care during the day to participate in an activity program and were overseen by separate staff. Memory care staff provided toileting for those residents when necessary and generally remained in the memory care to provide supervision for the remaining residents. Interviews with staff did reveal that the facility had some minor issues with ants and roaches, however those staff stated that management addressed the insect issues in a timely manner once staff reported the pest issue. Review of pest control invoices from 2022 and 2023 revealed that a pest control company serviced the facility twice a month and those services rotated between servicing the facility’s kitchen and the overall facility. Interviews with outside sources did not reveal any concerns or evidence of issues with pests in the facility. The Department has investigated the above-mentioned allegations and based on interview and record review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with General Manager Charles Bloom, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22). Facility management stated that staff disciplinary action ranged from immediate individual in-service training, verbal and written warnings, and termination, dependent on the severity of the alleged behavior. Additionally, any staff who were accused of misconduct were subject to an internal investigation and a meeting with facility management to discuss the allegation. Interviews with staff and outside sources revealed that in 2023, there was a staff member, Staff 1 (S1) who did not get along with other staff and was using profanity while in common areas of the facility and while in the presence of residents. Interviews confirmed that while S1 did not direct profanity towards residents, residents were present and could overhear S1’s comments. Additionally, there was at least one occasion where S1 and another staff member, Staff 2 (S2) got into an altercation that almost became physical while in the presence of residents. Interviews with staff and review of disciplinary documents revealed that S2 started the altercation and received a written warning. Due to S1’s difficulty to work alongside and ongoing profanity use in front of residents, S1 was terminated from employment. Additionally, interviews with staff and facility management revealed that a different staff member, Staff 3 (S3) was reported to have been yelling and screaming at a resident in memory care who was agitated during an overnight shift. Interviews revealed that S3 had prior disciplinary action and S3 resigned following the incident. Staff and facility management stated that the inappropriate behaviors were isolated to those specific staff members, which residents and outside sources supported during interviews. Interviews with management and review of staff roster revealed that none of the above staff currently work at the facility and were either terminated or voluntarily resigned. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. An exit interview was conducted with General Manager Charles Bloom, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, Feb 27, 2026 · control 08-AS-20230526124450

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Feb 27, 2026

87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met as evidenced by: Based on interview and record review, the Licensee did not comply with the section cited above in that 3 staff acted inappropriately towards or in the presence of residents. This posed a potential personal rights risk to 66 of 66 residents.the state’s words, verbatim · CDSS document, Feb 27, 2026

Plan of correction: All three staff members are no longer working at the facility. General Manager provided LPA with a copy of most recent inservice training regarding resident dignity during the visit. DEFICIENCY CLEARED.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to continue the Required 1-Year visit from 9/23/2025. LPA identified herself to and explained the purpose of the visit with General Manager Charles Bloom. The facility has a licensed capacity of 95 non-ambulatory residents, 32 may be bedridden on 1st floor only and has a waiver for 20 hospice residents. The Administrator for the facility is Charles Bloom and their certificate was valid and current. During visits on 9/23/25 and 10/9/25, LPA toured the facility and inspected a random sampling of resident rooms, private and common bathrooms, kitchen, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s ambient and water temperature were measured within regulatory requirements at multiple locations. LPA observed locked storage for resident medications and hazardous and/or toxic chemicals, both of which were stored separately from food supplies. According to Charles Bloom, no firearms or weapons are stored on the premises. LPA observed a minimum supply of 2-days of perishable food and 7-days of non-perishable food. The facility refrigerator and freezer were kept within requirements. Staff present at the facility during the time of the inspection had a criminal background clearance and association. LPA reviewed multiple resident and staff records. LPA was away from the facility between 12:05pm and 1:05pm. No deficiencies were cited on today’s date. An exit interview was conducted with General Manager Charles Bloom, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Oct 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Health Services Director Claire Molina. During today's visit, LPA reviewed facility records and observed residents in care. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. No deficiencies were cited on today's date. An exit interview was conducted with Health Services Director Claire Molina, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Sep 23, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Case Management - Annual Continuation visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with General Manager Charles Bloom. The facility is licensed for a maximum capacity of 95 non-ambulatory residents, 32 of which may be bedridden on the 1st floor. The facility has a waiver for 20 hospice residents. During today’s visit, the facility had a census of 65 residents. The Administrator for the facility is Charles Bloom and their certificate was valid and current. During visits on 8/9/2024 and 8/20/2024, LPA toured the facility and inspected a random sampling of resident rooms, kitchen, common areas, and outside space. No bodies of water were observed on the premises. LPA observed delayed egress in the facility's two memory care sections. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 112.3, 113.5, 114.1, 116.5, 117.0, and 118.2 degrees Fahrenheit in a random sampling of resident bathrooms. The facility’s internal temperature was measured at 71, 73, and 76 degrees Fahrenheit in different parts of the facility. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Charles Bloom, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 35 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. Continued on LIC809-C page… LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns. The General Manager will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days. No deficiencies were cited on today’s date. An exit interview was conducted with General Manager Charles Bloom, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Aug 20, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with General Manager Charles Bloom. During today's visit, LPA reviewed facility records and observed residents in care. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. LPA was away from the facility for approximately one hour between 12:00pm and 1:00pm. No deficiencies were cited on today's date. An exit interview was conducted with General Manager Charles Bloom, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Aug 9, 2024

Type of visit: Collateral

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Collateral visit. The LPA introduced himself and disclosed the purpose of the visit to General Manager Charles Bloom. During today's visit, the LPA conducted multiple interviews with staff. No deficiencies were observed, nor cited during today's visit. An exit interview was conducted with Health Services Director Claire Molina, to whom a copy of this report, and Licensee/Appeal Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, May 21, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Health Services Director (HSD) Claire Molina. LPA spoke with General Manager Charles Bloom on the phone. During today's visit, LPA observed residents in care, conducted a health and safety check, reviewed records, and interviewed staff and residents. The purpose of today's visit was to conduct follow up regarding a self-reported incident. On 5/6/2024, the Department received an incident report from the facility describing an incident that occurred on 4/25/2024, where Resident 1 (R1) fell in their bathroom at approximately 7:30pm and was discovered by Staff 1 (S1) the following morning at around 8:00am on 4/26/2024. [HSD was provided with an LIC811 Confidential Names List to identify individuals]. Interviews and review of R1's assessment records prior to the incident on 4/25/2024, revealed that R1 was independent of all care and did not require any assistance or status checks. Interviews and review of call buttons for the night of 4/25 and morning of 4/26 revealed that R1's call button in the bathroom was malfunctioning and did not register a call from R1's room into the facility's electronic system. Additionally, R1 was not wearing their personal call pendant during the incident. Interviews with S1 and R1 confirmed the narrative described in the incident report. HSD stated that call pendants have a fall detection software and R1 has a motion sensor system in their bedroom, however since R1 was not wearing their pendant and did not fall in the bedroom, both systems were not alerted. Interviews with staff and R1 revealed that facility staff contacted paramedics upon discovering R1 on the floor and R1 received medical attention and returned to the facility on 4/26/2024 with no injuries. Continued on LIC809-C page... HSD stated that since the incident, all residents' call buttons have been checked to ensure they are working correctly, staff have been provided an in-service training to check on all residents during their shift and track if residents are not attending meals, and R1 has been provided with reminders to wear their call pendant at all times. No deficiencies were cited in relation to this incident. An exit interview was conducted with General Manager Charles Bloom via telephone and HSD Claire Molina, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, May 13, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Health Services Director (HSD) Claire Molina. General Manager Charles Bloom arrived during the visit. During today's visit, LPA observed residents in care, conducted a health and safety check, reviewed records, and interviewed staff and residents. The purpose of today's visit was to conduct follow up regarding a self-reported incident. On 4/19/2024, the Department received an incident report from the facility describing an incident that occurred on 4/15/2024, where staff discovered that Resident 2's (R2) medication patch was not being administered as ordered. [HSD was provided with an LIC811 Confidential Names List to identify individuals]. Interviews with HSD revealed that the facility receives orders from the pharmacy and facility nurses review and approve the medication order prior to administering medications. Interviews with HSD and review of R2's electronic medication administration record (E-MAR) revealed that the medication patch was ordered to be given every 3 days or every 72 hours. R2's medication patch had a scheduling detail that was input into the E-MAR system stating that the medication patch was to be replaced every 4 days. Interviews with HSD stated that R2's pharmacy would occasionally provide scheduling details for medications, and HSD was provided with conflicting information from the pharmacy regarding if the pharmacy provided scheduling information for R2's patch. R2's E-MAR revealed that R2 had been receiving the medication patch every 4 days from October 2023 to 4/15/2024, which is not as the medication was ordered from R2's physician. Interviews with HSD revealed that R2 had not been experiencing any adverse effects due to the medication being administered not as ordered. The following deficiency for medication administration is being cited and noted on the attached LIC809-D page. An exit interview was conducted with General Manager Charles Bloom and HSD Claire Molina, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).the state’s words, verbatim · CDSS document, May 13, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87645(c)(2) · Plan of correction due date: May 13, 2024

87465 Incident Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidenced by: Based on interview and record review, the licensee did not ensure that R2's medication patch was administered as ordered by the physician. This poses a potential health risk to 65 of 65 residents in care.the state’s words, verbatim · CDSS document, May 13, 2024

Plan of correction: HSD and General Manager conducted an in-service training for staff on proper medication administration and verification on 4/16/2024 after discovering the medication error. DEFICIENCY CLEARED.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Riza Alvarez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by General Manager Charles Bloom, to whom LPA discussed the purpose of the visit. According to the facility’s license, the facility has a maximum capacity of ninety-five (95) non-ambulatory residents, thirty-two (32) of whom may be bedridden. LPA, accompanied by Resident Services Director Claire Molina and Care Director Ron Puno, toured the interior and exterior of the facility, and inspected several rooms in the facility's assisted living and memory care wings. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was comfortable and compliant with Regulations. Hot water temperature at taps accessible to residents were likewise compliant. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] No pools or bodies of water on the premises. Per General Manager, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers (19) were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed several staff and clients. LPA interviews did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Files reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Health Services Director Claire Molina to whom copies of this report and the Applicant/Licensee Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 28, 2023