306006421-4-6-2026-22-AS-EKIM-DSVVWJ-20260406164801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006421
Report Date: 04/06/2026
Date Signed: 04/06/2026 04:48:11 PM

Document Has Been Signed on 04/06/2026 04:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR/ DIRECTOR:	MORRIS,AUSTIN		FACILITY TYPE:	741
ADDRESS:	17803 IMPERIAL HWY		TELEPHONE:	(714) 777-9666
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY: 114		CENSUS: 98	DATE:	04/06/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Administrator- Austin Morris		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE
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	On April 6, 2026, at 8:00 AM, Licensing Program Analysts (LPAs) Edward Kim and Nancy Guillen conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs met with Resident Service Director (RSD) Mirian Im. LPAs met with Executive Director (ED) Austin Morris and explained the purpose of the visit. The facility is licensed to operate for one hundred fourteen (114) non-ambulatory, of which ten (10) may be bedridden, and maintains a hospice waiver for twenty (20) residents. The facility is a two-story structure, which consists of the following: one hundred twelve (112) resident bedrooms, thirteen (13) offices, one hundred sixteen (116) bathrooms, waiting area, hair salon, first floor activity area, second floor activity area, memory care dining room, main dining room, kitchen, memory care courtyard, and two outdoor areas with outdoor covered patio. LPAs toured indoor and outdoor physical plant with RSD Im. There is an fountain with no water in one of the outdoor areas. All rooms were inspected. Beds and bedding supplies were in good condition with adequate lighting as well as storage for each resident’s personal belongings were observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The following resident apartments were inspected: 105, 113, 120, 123, 135, 143, 158, 203, 254 and 271. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 106.7 degrees F and 114.2 degrees F. A comfortable temperature of 75 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/06/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/06/2026

NARRATIVE

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During the visit, LPA Kim observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Some storage areas for personal hygiene, toxins, cleaning supplies, and sharps objects were stored and inaccessible to residents. LPAs observed housekeeping cart kept under staircase across from room 126 had an Envio Care Natural Disinfectant spray bottle and Betco Smoke & Odor Spray Bottle that were not locked away and were accessible for residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food and supplies are stored in the kitchen and in a storage room closet next to the kitchen. Emergency water is stored in a storage closet in Skilled Nursing across from room 183 and room 184. A working telephone (714) 844-0967 remains available.

LPA Kim reviewed the facility’s plan of operation, emergency and disaster plan, and fire/safety drill log. The facility last conducted an Emergency Drill on March 25, 2026. The facility has fire extinguishers that are charged, and they were all serviced on October 23, 2025. Smoke detectors and carbon monoxide detectors were operable and tested by CAL Building Systems on March 23, 2026. First Aid was maintained and contained all the necessary elements.

LPA Kim conducted an audit of ten (10) resident files (R1-R10), ten (10) staff files (S1-S10), and medication and medication administration record that were in order and complete. LPA conducted seven (7) resident interviews and six (6) staff interviews.

Based on today’s visit, a deficiency is being cited as per the Title 22 Division 6 Chapter 8 of California Code of Regulations (CCR). LPA observed in staircase across from room 126, there was a housekeeping cart left under the staircase with cleaning supplies left out. LPA observed an Envio Care Natural Disinfectant spray bottle and Betco Smoke & Odor Spray Bottle that were not locked away and were accessible for residents.

An exit interview was conducted, and a copy of this report, LIC809D, and appeal rights were provided to Executive Director Austin Morris.

NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/06/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/06/2026 04:48 PM - It Cannot Be Edited

Created By: Edward Kim On 04/06/2026 at 04:24 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BAYSHIRE YORBA LINDA	FACILITY NUMBER: 306006421
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

87309(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPAs observed an Envio Care Natural Disinfectant spray bottle and Betco Smoke & Odor Spray Bottle that were not locked away and were accessible for residents in the staircase across from room 126, This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/20/2026
	Plan of Correction
1 2 3 4	POC corrected during visit. Administrator placed the cart in a storage area that is locked and inaccessible to residents.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:

	Edward Kim
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/06/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2026

LIC809 (FAS) - (06/04)

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