Aegis Assisted Living of Laguna Niguel.

out of 9 witnesses interviewed reported they had no knowledge of any of R1's belongings being stolen. W1 did not respond to LPAs request for an interview. The Executive Director reported that staff looked for R1's rings but could not find them. The Care Director reported that their internal investigation could not determine what happened to the rings. A review of R1's file shows R1 did not have an inventory list completed at the time of move in. R1 passed away on July 31, 2025. None of the evidence gathered supports the allegation, therefore the allegation is deemed Unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.

(Continued from LIC 9099) On February 5, 2025, R1 developed a wound on their left hip and on the heels of their feet. R1 received Home Health services through Kaiser Permanente for catheter care and heel wounds. On February 5, 2025, R1 was transported to Kaiser Hospital due to a ruptured urethra and for further evaluation of the hip and heel wounds. R1 returned to the community on February 6, 2025, after hospital treatment with a diagnosis of Urinary Tract Infection and orders for medication treatment. Four days later, on February 10, 2025, the Health Care Director requested R1 be sent out to Kaiser Hospital for further medical evaluation for the hip and heel wounds that were not improving. Resident was treated and admitted to the hospital and was discharged on February 18, 2025, to a Skilled Nursing Facility. During the course of treatment the Power of Attorney (POA) received communication from both facility staff and Home Health regarding the hip and heel pressure wounds. Facility had spoken to the Power of Attorney (POA) on January 29, 2025, requesting the resident receive hospice care for the open wounds in order for the resident to return to the facility. POA declined hospice services due to a scheduled surgery for kidney stones. The physician was notified and the nurse treated the affected area. POA was aware of R1’s declining health and management discussed with POA to consider a personal caregiver to provide supervision to prevent further falls or injuries but family was not able to provide a personal caregiver. Care staff would do frequent body checks and rotate R1, based on R1’s service plan, which was documented by facility staff and Home Health. Due to statements and documents, nurses’ progress notes and home health notes there is not enough information to support the allegation that Resident #1 sustained stage 4 pressure injury while in care due to Neglect/Lack of Care and Supervision. The allegation is Unsubstantiated. It was alleged that Resident sustained a fracture while in care due to lack of care and supervision. Resident #1 (R1) had eleven unwitnessed falls in 2023-2024 in their bedroom; due to R1 getting out of bed and walking. Per Physician’s Report dated October 31, 2024, R1 is unable to transfer to and from the bed and is non-ambulatory. R1 also is diagnosed with Mild Cognitive Impairment. (Continued on LIC 9099-C1) 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 26 27 28 29 30 31 32 (Continued from LIC 9099-C) The Department reviewed Unusual Incident Reports for R1’s unwitnessed falls for the following dates: 8/10/2023, 8/22/2023, 9/24/2023, 9/25/2023, 10/27/2023, 03/22/2024, 03/25/2024, 04/01/2024, 04/10/2024, 05/04/2024, 05/09/2024 and 07/02/2024. R1’s needs and service plan was updated on 08/22/2023 following their first two falls and again on 12/23/2023 following their next three falls. After continuing to sustain falls, the facility updated the needs and service plan on 03/19/2024; 06/26/2024; 09/21/2024; and 11/20/2024 with suggested fall interventions which included: toilet resident before and after meals and before bedtime, frequent checks, involve resident in activities during the day and monitor for medication side effects. On April 4, 2024, management implemented fall risk prevention measures by requesting a low bed, frequent checks on R1 and discussed extra care and supervision. POA was unable to provide a personal caregiver but facility staff conducted additional status checks, every thirty minutes on R1 to prevent falls. Record review did not report any injuries related to the falls; both by the facility and home health. On February 10, 2025, R1 was transported to Kaiser Hospital due to pressure wounds not improving and to be evaluated by an orthopedic surgeon regarding a fracture. R1 was diagnosed with a left femur fracture. . The surgeon reported the fracture to be old, chronic and nonoperative and the fracture was healing and surgery was unnecessary. No time frame was provided and the injury was reported to be old. Facility staff accompanied R1 to appointments and there is no documentation regarding R1 having a fractured hip prior to diagnosis. R1 was treated at the hospital and was given medication for pain and discomfort. Although R1 had multiple falls and sustained a fracture, it remains unclear the source of cause for the fracture and therefore whether it was due to neglect. There is not enough information to support the allegation that the: Resident sustained fracture while in care due to lack of care and supervision. Based on interviews conducted and records reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore the allegations that the: Resident sustained a stage 4 pressure injury while in care and the Resident sustained a fracture while in care due to lack of care and supervision are Unsubstantiated. An exit interview was conducted with Kurt Knauer, General Manager, and a copy of this report was left at the facility.

Witness (W1) reported it to Staff 1 (S1). R1 resides in memory care which has a secure perimeter with delayed egress exits. S1 attempted to assist R1 but R1 was not responding to S1. S1 called for Staff 2 (S2) to assist. W1 reported to law enforcement that S1 and R1 began punching each other. W1 reported to LPA that they did not actually see S1 hit R1 but assumed they were being hit because R1 was yelling. W1 reported to law enforcement that R1 was yelling, “Kill her. Kill her.” W1 reported to LPA they didn’t remember what R1 said. S1 reported that R1 had defecated in the hallway, and they wanted to get them out of their clothing and shoes because they were soiled. S1 stated that R1 became combative and tried to hit them. S1 stated that R1 started to lose their balance and started to fall so S1 held them up so they would not fall. S1 stated that they called S2 who came and took off R1’s shoes and asked R1 to walk to their room and R1 started to walk to their room. S1 and S2 both reported that once in the room they showered R1, put clean clothes on R1 and put R1 to bed. S1 denied hitting R1 and reported they have never abused any residents. S2 reported they did not witness S1 hit or abuse R1 in any way. No other staff members or witnesses were present during the incident. Law enforcement took a report on September 23, 2021, but did not take any action. LPA attempted to interview R1 but R1 did not recall the incident. Based on the evidence gathered, the allegation is deemed Unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, resident sustained injuries while in care, revealed the following. It was alleged that Resident 1 (R1) sustained bruises on their forearms which were caused by facility staff. R1 was interviewed but did not recall how their arms were bruised. 5 out of 5 staff interviewed were unaware of R1 bruising until they were told about it. 5 out of 5 staff interviewed denied causing any injuries to R1 or any residents. The General Manager stated that R1’s responsible party informed them of the bruise and asked staff about it but no one could explain how it occurred. None of the staff interviewed could explain how R1 sustained their bruises. R1 resides in memory care which has a secure perimeter. R1 is on 2 medications, that can cause bruising, Quetiapine Fumarate and Lorazepam, but it is rare. The facility does not have any surveillance cameras. R1’s responsible party reported the unexplained bruises could have been caused by facility staff. The facility General Manager reported that they spoke to memory care staff, and no one reported any falls or incidents regarding R1 that could explain the bruises. LPA toured the memory care unit and R1’s room. No obstacles or hazards were observed. 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 26 27 28 29 30 31 32 A review of facility documents for August 2021 and September 2021 do not list R1 as having any accidents or injuries. It is unknown how R1 sustained their bruises. None of the evidence gathered supports the allegation, therefore the allegation is deemed Unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. Regarding the allegation, the facility does not have adequate staffing to meet residents’ needs, the investigation revealed the following. It was alleged that the facility is understaffed in memory care and that the residents may not get their meals. No other specific details were provided concerning the lack of staff at the facility other than care would not be provided. At the time of the report the facility census was 70, with 22 of the residents residing in memory care. A review of the facility schedule shows the facility has an average of 25 care staff working each day including medication technicians, 13 for assisted living and 12 for memory care. For the months of August and September 2021 the Agency (CCL) received a total of 6 incident reports (LIC 624). None of the incident reports received give cause for concern for residents’ health and safety and none of them warranted a follow up visit. During the visit on January 27, 2022, LPA observed all the residents in memory care eating in the dining area. There have been no other reports that the facility does not have adequate staffing. Based on the information gathered through observation and a review of records, the allegation that the facility does not have adequate staffing to meet resident’s needs is deemed Unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of the report was provided.

On September 22, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. General Manager (GM) Kurt Knauer was present and assisted on today's inspection. LPA observed that Kurt Knauer has a valid Administrator certificate which expires on May 16, 2026. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for ninety six residents, of which twenty one may be bedridden, and has a hospice waiver for fifteen. The facility is a two story building with resident bedrooms on the first and second floor, bathrooms are located in each resident apartment, a commercial kitchen, three dining halls, three activity rooms, two medication rooms, multiple staff offices, and a courtyard in the center of the facility. The facility has two memory care units and the rest of the facility operates as Assisted Living. On today's visit, there are seventy one residents in care, of which five are on hospice. LPA, accompanied by the GM, conducted a tour of the interior portion of the facility. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA randomly inspected resident bedrooms on the first and second floors of the facility. Resident bedrooms were clean and free of hazards. Resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. Resident beds had clean linens and blankets. LPA also inspected the bathrooms in each of the resident apartments inspected. Bathrooms were clean. Bathrooms were equipped with grab bars and non skid floors. Faucets and toilets were operational. Hot water temperature measured between 105.6 to 116.2 degrees Fahrenheit. CONTINUED ON LIC809-C 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 26 27 28 29 30 31 32 LPA inspected the commercial kitchen and observed it to be clean. The kitchen has a two day perishable and a seven day non-perishable food supply on hand. Kitchen knives and sharps are stored inaccessible to residents in care. LPA also observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA inspected all other facility common areas such as the dining halls, activity rooms, storage rooms, and observed them to be clear of any hazards. LPA observed emergency evacuation chairs in each of the facility stair wells. LPA observed the facility passed their most recent fire inspection on March 11, 2025, in which the facility's fire sprinklers were tested. LPA observed fire extinguishers mounted on the walls on the first and second floors of the facility. Fire extinguishers were observed to be charged and serviced as of March 12, 2025. LPA observed the facility conducted their most recent emergency disaster drill on August 20, 2025. LPA observed the centrally stored medications to be kept in locked medicine carts located in the medication rooms on the first and second floor. LPA observed each medication room to have a First Aid Kit and they had all the required components. LPA reviewed eight resident files. All the required documents were present and current in the resident files reviewed. LPA reviewed residents' medication and medication records. LPA reviewed eight staff files. All staff are background cleared and associated to the facility. Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with General Manager Kurt Knauer and a copy of the report was provided.

CONTINUED FROM FORM LIC9099 Regarding the allegation that Facility staff is violating resident’s personal rights by not allowing visitors to see the resident , the following has been concluded: Based on records reviewed and interviews conducted, resident R1 as well as staff members and witnesses interviewed deny any interference from facility staff into R1's ability to receive visitors as he pleases. R1 stated that he is fully able to receive visits from whoever he would like. A review of resident records for R1 additionally allowed LPA to verify the identity of R1's responsible party and attorney-in-fact. A signed letter from the resident's stated primary care physician dated February 29, 2024 indicates that " Due to [R1's] age and chronic medical conditions, I request that his life not be disturbed at this time by visits from other family than his daughter who has been instrumental in acting in his behalf to help him recover from recent physical trauma and hospitalization and securing an appropriate series of care facilities that meet his physical and emotional needs. " The letter further states that " [R1] was seen in my office on 02/26/24 where I thoroughly interviewed him and found him physically improved and mentally competent to understand his life situation and make informed decisions as to his preference to not be unduly disturbed or manipulated. " Regarding the allegation that Staff member was engaged in a verbal altercation in the presence of the residents , the following has been concluded: Based on witness, staff and resident interviews conducted, no instances of staff engaging in loud arguments, altercations or talking inappropriately to visitors could be corroborated. Multiple statements to the opposite were however made, emphasizing how nice and welcoming the facility feels overall. As a result of this investigation, both allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred. An exit interview was conducted with General Manager Kurt Knauer who authorized facility staff to sign on his behalf and a copy of this report was provided to a facility representative.

Licensing Program Analysts (LPAs) Joseph Alejandre and Rose Rupert made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted entry by staff. LPAs met with General Manager Kurt Knauer and explained the reason for the visit. LPAs and General Manager toured the facility. The facility has a capacity of 96, 75 non-ambulatory, of which 21 may be bedridden and a hospice waiver for 15. The facility is a two story building with a central courtyard in the center. The facility has one kitchen with multiple dining and activity rooms. All the rooms are private with the their own bathroom. The memory care units are on the first floor, one unit (Golden Lantern) is on the North side of the building and the other unit (Blue Lantern) is on the South side of the building. Both memory care units have delayed egress exits. The LPAs tested the delayed egress exits and they are operational. LPAs observed the See Something Say Something poster (PUB 475) posted in the main entry way of the facility. LPAs observed each stairway had an emergency evacuation chair. All fire extinguishers are fully charged. LPAs inspected seven resident rooms. LPAs observed each resident room inspected was clean and had the required furnishings. Hot water was measured in each room inspected. Hot water measured from 105.9 to 118.9 degrees Fahrenheit. LPAs observed emergency food and water stored in a supply closet. LPAs toured the kitchen and dining room. The kitchen is clean and organized. LPAs observed temperature logs for the refrigerators and freezers posted in the kitchen. The refrigerators and freezer are kept at the required temperatures. LPAs observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The last fire drill was conducted on August 6, 2024. LPAs observed the medication cart is kept locked in the health and wellness office. LPAs inspected the first aid kit. The first aid kit did not contain a first aid manual. LPAs and the General Manager toured the courtyard. No bodies of water observed. The fountain has been converted into a large planter. There are numerous tables and chairs with umbrellas to sit outside. During the visit LPAs observed residents playing bingo in the activity room and LPAs observed a sing a long in the activity room. The fireplaces in the library and the downstairs parlor are screened. No obstacles or hazards observed inside or outside of the facility. LPAs reviewed 7 resident files, no discrepancies observed. LPAs reviewed 5 staff files, no discrepancies observed. 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 26 27 28 29 30 31 32 Staff files reviewed had the required training including CPR/First aid. LPAs interviewed staff and residents. All staff interviewed and files that were reviewed are background cleared and associated to the facility. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.