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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006421
Report Date: 11/20/2025
Date Signed: 11/20/2025 04:28:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2025 and conducted by Evaluator Edward Kim
COMPLAINT CONTROL NUMBER: 22-AS-20250131171222
FACILITY NAME:BAYSHIRE YORBA LINDAFACILITY NUMBER:
306006421
ADMINISTRATOR:COLEMAN, CHADFACILITY TYPE:
741
ADDRESS:17803 IMPERIAL HWYTELEPHONE:
(714) 777-9666
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:114CENSUS: 103DATE:
11/20/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Resident Services Director- Mirian ImTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Licensee is not ensuring that staff are adequately trained.
INVESTIGATION FINDINGS:
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On November 20, 2025, at 8:15 AM, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Resident Services Director (RSD) Mirian Im and explained the purpose of today’s visit. LPA Kim called Executive Director Austin Morris who stated they would not be here for today's visit and stated that RSD Im could sign on behalf of the facility.

The investigation consisted of the following. LPA Kim toured the facility with ED Austin Morris. LPA requested and obtained copies of the resident roster, staff roster, and resident files which include Physician’s Report, Appraisal/Needs and Services Plan, staff training hours, and other pertinent records. LPA conducted interviews with nine staff and eight residents.

The investigation revealed the following:
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 22-AS-20250131171222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BAYSHIRE YORBA LINDA
FACILITY NUMBER: 306006421
VISIT DATE: 11/20/2025
NARRATIVE
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Allegation: Licensee is not ensuring that staff are adequately trained.
It is alleged that care staff are missing initial training and Executive Director said to remove training because they are not in budget. It is alleged the facility cancelled January Training.

Based on interviews conducted, five out of nine staff corroborated the allegation the facility is not ensuring staff are adequately trained. Eight out of eight residents and four out of nine staff denied licensee is not ensuring that staff are adequately trained. Four out of nine staff members stated the facility does not have regular required training. A staff member stated the facility had canceled training dates for December 2024 and January 2025. S9 stated that staff who were hired in 2024 did not have the initial completed training.

Based on records reviewed, LPA audited 7 staff training files. Caregivers, Medication technicians, and other care staff need an initial 40 hours of training once hired and then an additional 20 hours of additional annual training. As of November 20, 2025 at the time of the visit, LPA obtained and reviewed all in-service and online training programs, and discovered the facility did not have the initial 40 hours of training service for the seven staff [S2 (care staff), S3 (caregiver), S4 (caregiver), S5 (caregiver), S6 (medication technician), S7 (medication technician), and S8 (care staff)].

LPA reviewed the staff online training program and in-service hours that demonstrated the staff did not complete the required hours for 2025. S2 only completed 2 hours out of 20 hours for 2025. S2 attended 2 in-service training with no listed duration of time. S3 completed 10.5 hours out of 20 hours required for 2025. S3 attended 7 in-service training with no listed duration of time. S4 completed 1 hour out of 20 hours required in 2025. S4 attended 4 in-session training for 2025 with no duration of time. S5 completed 4 hours out of 20 hours required for 2025. S6 completed 3 hours out of 20 hours required for 2025. S6 attended 8 in-service training for 2025 with no duration of time listed. S7 completed 6 hours out of 20 hours required for 2025. S7 attended 1 in-service training for 2025 with no duration of time listed. S8 completed 4.5 hours out of 20 hours required for 2025. S8 attended 1 in-service training for 2025 with no duration of time listed.

Continued on LIC9099C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20250131171222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BAYSHIRE YORBA LINDA
FACILITY NUMBER: 306006421
VISIT DATE: 11/20/2025
NARRATIVE
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Based on information gathered, there is sufficient evidence to corroborate the above allegation. Based on five out of nine staff interviews who corroborated the facility is not ensuring staff are trained adequately. Based on record review, seven out of seven staff did not have a record of completed initial training and the required 20 hours annual trainings for 2025.

Therefore, based on the interviews which were conducted and the records that was reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Licensee is not ensuring that staff are adequately trained deemed SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. One deficiency is being cited on the attached LIC9099D.

Exit interview was conducted a copy of the report, appeal rights, LIC9099D, and LIC811 were provided to Resident Services Director Mirian Im.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20250131171222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BAYSHIRE YORBA LINDA
FACILITY NUMBER: 306006421
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2025
Section Cited
CCR
87411(c)
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87411 Personnel Requirements- General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
This requirement is not met as evidenced by:
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Licensee states they will send a completed initial training and annual training of all current employees, S4, S7, and S8, to CCLD via email to edward.kim@dss.ca.gov by POC due date December 5, 2025.
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Based on observations, record review, and interviews, seven out of seven staff did not complete their initial training and their annual 2025 training. This poses a potential health, safety, and/or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4