Aegis Living Dana Point

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on an incident report submitted to the department. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report dated 09/03/2026 reported Resident 1 (R1) was found on the floor by the resident's bed and was subsequently diagnosed with a right hip fracture. The resident's service plan dated 08/06/2026 indicated the resident was a fall risk. The resident had hip surgery and is currently at a skilled nursing facility. LPA toured the facility and observed the following: Facility is in the process of replacing carpet in the dining room. Residents in memory care were observed to be participating in activities or relaxing and appeared well taken care of. Facility appears clean and sanitary. No health concerns noted. No deficiencies noted during today's visit. Exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 16, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to the facility. The purpose of today’s visit was to conduct the annual required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 76 non-ambulatory residents of which 10 may be bedridden. Facility has a hospice waiver for 16 residents and there are 13 residents on hospice during today's visit. The two story facility houses Assisted Living and Memory Care apartments including multiple, activity areas, med rooms, two common dining rooms, bistro, reading room and salon as well as an outdoor space. Administrator Eric Medor has a current administrator certificate expiring on 11/20/2026. Upon entry, facility appears clean, safe and sanitary. LPA Lyman along with Administrator Eric Medor toured the facility at 9:22 AM. LPA toured the physical plant, checked food service, facility documents and the first aid kit. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105.2 degrees F and 119 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPA checked medication room and medication carts were found to be secured. Common areas were clean and clear of hazards, doorways were free of obstructions. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances are operational during today's visit. Toxins are secured. Smoke detectors and carbon monoxide detectors are tested monthly in house and fire/ sprinkler inspections were last conducted on 11/24/2025 by third-party South Coast Fire and Security. Fire extinguishers were fully charged. LPA reviewed the emergency disaster plan and plan is complete. Facility conducts quarterly emergency drills with the last drill conducted on 01/15/2026. Continued ON LIC 809C DATED 01/27/2026 LPA observed ample emergency food and water as well as evacuation chairs at stairwell. Outside grounds were toured. LPA observed multiple outside patio areas. There is ample outdoor shaded seating for residents. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. LPA reviewed select staff and resident files. Resident files included all required documents including updated physician reports, pre-appraisals, admission agreements and physician orders for bed rails as indicated. Staff files reviewed contained proof of CPR training, health screen/ TB and required annual training. LPA observed medication administration and storage. Medications appear to be administered per physician order. Based on the observations made during today's visit, No deficiencies are being cited. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 27, 2026

Allegation investigated: Staff was verbally aggressive to resident.

On January 9, 2026, at 9:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced subsequent complaint visit to deliver findings at the facility. LPA Kim met with Executive Director (ED) Eric Medor and explained the purpose of the visit. The investigation consisted of the following. LPA Kim toured the facility with ED Medor. LPA Kim reviewed and obtained copies of resident roster, staff roster, and one resident’s record, which include: Identification and Emergency Information, incident report, progress notes, Physician's Report, Needs and Services Plans/Reappraisal, and other pertinent records. LPA reviewed and obtained two staff records which include: LIC501/Job Application and contact information. LPA conducted interviews with one resident, four staff, and one witness. The investigation revealed the following: Continued on LIC9099C Substantiated Allegation: Staff was verbally aggressive to resident It is alleged that the staff member was aggressively communicating with the resident and in close proximity of the resident. Based on record reviews, the facility progress note stated on December 18, 2025, resident attempted to use the stairway to come down the stairs, but S1 attempted to redirect resident to use the elevator. R1 refused to listen and was speaking aggressively towards S1. S1 raised their voice which led resident to cry and their responsible party (RP) escorted them out of the facility. The resident spent the night at the responsible party’s place. An email dated December 18, 2025, states S1 is under suspension and scheduled to return on Monday, December 22, 2025. The email also stated the facility submitted a report to report the incident to California Department of Social Services Orange County Regional Office, local law enforcement, and the local ombudsman. On December 19, 2025, the facility received a resignation letter from S1. Based on interviews conducted, three out four staff, one resident, and one witness corroborated that S1 was verbally aggressive with the resident. One staff out of four staff denied the allegation. S3 stated that S1 was yelling with an aggressive angry tone and demanor towards the resident. W1 stated they saw S1 in the face of the resident yelling in anger. S2 and S4 were not present at the time of the incident but confirmed they heard that S1 was yelling at the resident. Based on the information gathered, there is sufficient evidence gathered to corroborate the above allegation. It is determined that three out of four staff corroborated that the staff was verbally aggressive to resident. It is also determined through progress notes and email correspondence, that the incident did occur where the staff was verbally aggressive with the resident. Therefore, based on LPA's interviews and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff was verbally aggressive to resident deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. A deficiency is being cited on the attached LIC9099D. Exit interview was conducted, and a copy of the report, LIC9099D, LIC811s, and the appeal rights were provided to Executive Director Eric Medor.the state’s words, verbatim · CDSS document, Jan 9, 2026 · control 22-AS-20251218142242

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jan 30, 2026

87468.1(a)(3) ...Residents... shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions .... This requirement is not met evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above. S1 was verbally aggressive with R1. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Licensee states they will have a training session with staff on the topic of how staff should interact with residents in de-escalation situations and submit the plan and sign-in sheet to CCLD via email to edward.kim@dss.ca.gov by POC due date January 30, 2026.

Allegation investigated: Due to lack of supervision, resident was assaulted by another resident

This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Nancy Guillen for the purpose of investigating the above-mentioned complaint allegation. LPAs met with Administrator (AD) Sheila Nazareth and Care Director (CD) Iona Soptirean, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that due to lack of supervision, resident was assaulted by another resident revealed the following: During the course of the investigation, LPAs inspected the facility, interviewed AD, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Individualized Service Plan dated December 10, 2024, the facility’s recent communications with R1’s doctor, and the facility’s progress notes for R1. CONTINUED Unfounded It was alleged that a resident was hit by another resident and no injuries were sustained. LPAs inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPAs interviewed AD who stated that on January 11, 2025, R1 was agitated and aggressive in the memory care unit, R1 was taken on a walk through the assisted living section by Staff #1 (S1) to calm down, an altercation allegedly occurred between R1 and Resident #2 (R2) in the assisted living section, and R1 was redirected back to the memory care unit. However, AD did not witness the alleged altercation. LPAs interviewed S1 who denied there was an altercation between R1 and R2 and stated that on January 11, 2025, S1 was holding R1’s hand while taking R1 on a walk through the assisted living section and R1 accidentally bumped into R2 while they were walking by R2, R1 was not aggressive, there was no physical or verbal altercation, and the bump was minor and did not lead to any injuries or falls. R1 is no longer at the facility. LPAs interviewed R2 and another resident who witnessed the alleged incident who did not corroborate the allegation. LPAs interviewed six other residents and did not obtain information corroborating any concerns about safety, staffing, or care and supervision. LPAs reviewed R1’s Individualized Service Plan dated December 10, 2024, the facility’s recent communications with R1’s doctor, and the facility’s progress notes for R1 which indicate that the facility has been working with R1’s doctor and family to address R1’s behaviors. The information obtained showed that the incident did not occur as alleged and that instead R1 accidentally bumped into R2. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Feb 3, 2025 · control 22-AS-20250128082334

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Lyman and Fred Arias conducted an unannounced visit to the facility. The purpose of today’s visit was to conduct the annual required inspection. LPAs were allowed entry into the facility and explained the reason for the visit.. Facility is licensed for 130 non-ambulatory residents of which 50 may be bedridden. The two-story facility houses Assisted Living (AL) and Memory Care (MC) apartments. The first floor houses 11 AL apartments, 19 MC apartments, three activity rooms/areas, med room, two common dining rooms, 1 private dining room, kitchen, sitting areas, staff offices, family room, spa, two common bathrooms and courtyard. The second floor houses 36 AL apartments, reading room, salon, and laundry room. There are 11 residents on hospice. LPAs along with Administrator (AD) Eric Medor toured the facility at 9:15 AM. All apartments have the necessary furnishings and private bathrooms. LPAs toured the physical plant, checked food service, and the first aid kit. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 104.7 degrees F and 117.5 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPAs checked medication room and medication carts and were found to be secured. Common areas were clean and clear of hazards, doorways were free of obstructions. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances are operational during today's visit. LPAs observed the facility to be clean and sanitary. Toxins are secured. Smoke detectors and carbon monoxide detectors are tested monthly in house and fire/ sprinkler inspections were last conducted on 10/17/2024 by third-party SouthCoast fire and security. Fire extinguishers were fully charged. LPAs reviewed the infection control plan and emergency disaster plans and plans are complete. Facility conducts quarterly emergency drills with the last drill conducted on 11/13/2024. LPAs observed ample emergency food and water. Continued ON LIC 809C DATED 1/09/2025 Outside grounds were toured. LPAs observed multiple outside patio areas. There is ample outdoor shaded seating for residents. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. LPAs observed medication administration and storage. Medications are being administered per physician order. Based on the observations made during today's visit, No deficiencies are being cited. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced visit to the facility for purpose of conducting required 1-year annual inspection. LPA arrived at the facility and was greeted at the facility by the Concierge, Ashley Stewart. Eric Medor, General Manager joined the LPA for the inspection upon LPA;s arrival. The LPA explained the reason for the inspection. The two-story facility houses Assisted Living (AL) and Memory Care (MC) apartments. The first floor houses 10 AL apartments, 19 MC apartments, three activity rooms/areas, med room, two common dining rooms, 1 private dining room, kitchen, sitting areas, staff offices, family room, spa, two common bathrooms and courtyard. The second floor houses 36 AL apartments, reading room, salon, staff lounge and laundry room. LPA observed the facility to be clean and sanitary. LPA toured 4 apartments. All apartments have the necessary furnishings and private bathrooms. Hot water measured was observed to be between 105 and 120 degrees Fahrenheit. LPA observed all windows were screened. Medications are locked in the Med Rooms. The facility has an activity calendar including the following activities: exercise, comedy, religious activities, movie/tv shows, board games and more. There is a 2-day supply perishable food and a 7-day supply of non-perishable food on hand. Emergency food and water are located in storage on the second floor. LPA observed a walk-in refrigerator, a walk-in freezer, a walk-in pantry and noted the kitchen has working appliances and can be locked from all entrances. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and double locked in the laundry rooms. LPA reviewed a document called Fire Alarm & Emergency Communication System Inspection & Testing Form. This form indicated that the facility smoke/carbon monoxide alarms and sprinkler system were tested on 9/6/2023 by Southeast Fire & Security.All fire extinguishers are fully charged. The service tags indicates they were last serviced on 2/12/2024. Emergency Phone Numbers, Exit Plan, Activity Calendar & Menu are all posted and available for review. No deficiencies were noted. LPA issued two technical assistances regarding the Disaster Plan and postings. An exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Feb 22, 2024

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.