Aegis Assisted Living at Shadowridge.

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).

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).

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… 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 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).

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).

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.

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... 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 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).

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] 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 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.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with General Manager Charles Bloom and Health and Wellness Director Dustin Banks. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received 03/27/2023). The LIC624 described an as-needed (PRN) medication incident occurring on the evening of 03/16/2023, involving Staff #1 (S1) and Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. The medication incident did not result in any adverse symptoms for R1. During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were safe. LPA also reviewed pertinent care records and interviewed relevant staff. Based on specific details and context surrounding the incident, no deficiency was issued. Also, no deficiencies were observed or cited during today’s visit. An exit interview was conducted with Bloom and Banks, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.