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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006421
Report Date: 04/23/2026
Date Signed: 04/23/2026 05:22:33 PM

Unsubstantiated


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
08/19/2025 and conducted by Evaluator Edward Kim
COMPLAINT CONTROL NUMBER: 22-AS-20250819172952
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: 95DATE:
04/23/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator- Austin MorrisTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff does not respond to call button in a timely manner.
Staff do not ensure resident's care plan is updated.
INVESTIGATION FINDINGS:
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On April 23, 2026, 9:30 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced initial complaint visit at the above facility for the above allegations. LPA Kim met with Administrator Austin Morris and explained the purpose of the visit.

The investigation consisted of the following: on August 27, 2025, LPA Kim conducted a physical plant tour inside and outside of the facility and no concerns were observed. LPA Kim reviewed one staff record, which include: LIC501, LIC503, staff training records, and nine resident’s record, which include: Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans/Reappraisal, Medication Administration Records, Incident reports, and other pertinent records.

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

DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
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 6
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
08/19/2025 and conducted by Evaluator Edward Kim
COMPLAINT CONTROL NUMBER: 22-AS-20250819172952

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: 95DATE:
04/23/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator- Austin MorrisTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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9
Staff are not trained to provide medications to residents.
INVESTIGATION FINDINGS:
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On April 23, 2026, 9:30 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced subsequent complaint visit at the above facility for the above allegation. LPA Kim met with administrator Austin Morris and explained the purpose of the visit.

The investigation consisted of the following: on August 27, 2025, LPA Kim conducted a physical plant tour inside and outside of the facility and no concerns were observed. LPA Kim reviewed one resident’s record, which include: Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans/Reappraisal, Medication Administration Records, Incident reports, and other pertinent records.

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: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20250819172952
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: 04/23/2026
NARRATIVE
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Allegation: Staff are not trained to provide medications to residents.
It is alleged that a staff administered a medication without training. It is also alleged that it was not charted in the Medical Administration Record and was recorded written on a separate medication chart.

Based on record review, R1’s Controlled Drug Administration Record had S1 sign off on August 16, 2025, at 1:32 AM. R1’s Medication Administration Record only has a record of another staff administering the medication on August 16, 2025, at 9:08 PM. While reviewing S1’s training, the staff did not have training to administer medication to residents. Based on interviews conducted four out of five staff confirmed the allegation. One staff out of the five staff could not confirm or deny the allegation. Four out of five staff stated, S1 assisted R1 with their prescribed medication which was self administered.

Based on information gathered through interview and record review, the preponderance of evidence standard has been met, therefore, the allegation Staff are not trained to provide medications to residents was found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6 Chapter 8.

An exit interview was conducted, and a copy of this report including LIC811, and the appeal rights were provided to Adminstrator Austin Morris.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20250819172952
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: 04/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2026
Section Cited
CCR
87411(c)(3)(D)
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87411 (c)(3)(D)All RCFE staff who assist residents... shall receive initial and annual training. The training shall include... the following: (D)Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4)...
This requirement is not met evidenced by
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Licensee states they will conduct an in-service training with S1 and send a copy of training S1 understand that authorized staff with medication knowledge required to safely assist with prescribed medications which are self administered will only administer medication to residents.
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Based on observation, the licensee did not comply with the section cited above. LPA observed S1 administered a medication to R1 according to Controlled Drug Administration Record of R1. This poses an potential health or safety risk to persons in care.
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Licensee will send a copy of the email of completed training to CCLD via email to edward.kim@dss.ca,gov by POC due date May 7, 2026
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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: 04/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20250819172952
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: 04/23/2026
NARRATIVE
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Allegation: Staff does not respond to call button in a timely manner.
It is alleged the time between the residents' pendants are pushed and when a caregiver can respond can be up to 20 minutes.

Based on record review, the facility policy Resident Alert Call System states that the facility is equipped all residents with an alert call system. Staff will respond to all activation of the resident call system. It also states when a resident alert call system is activated, a caregiver will respond. There is no indication of a time frame of how fast the staff needs to respond to a call button being pressed. Based on interviews conducted, seven out of eight staff and nine out of nine residents denied the allegation. One out of eight staff confirmed the allegation. All residents stated that the staff responded in a timely manner when their call button was pressed. They also stated there was not a time they waited more than twenty minutes to receive assistance after pressing the call button. Seven out of eight staff stated that the staff responds within fifteen minutes to when a call button is pressed.

Based on observations, on September 17, 2025, LPA observed two resident rooms where staff responded to call button being pressed within five minutes. On April 23, 2026, LPA observed five resident rooms where staff responded to the call button being pressed between 32 seconds to 19 minutes.

Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

Allegation: Staff do not ensure resident's care plan is updated.
It is alleged new residents are not updated to shower schedule and level of care changes addressed correctly, for weeks.

Based on record review, four residents out of nine residents have a shower schedule posted on their bathroom door. Based on resident appraisals, the facility keeps an update of all resident care plan needs. Based on interviews conducted, seven out of eight staff and nine out of nine residents denied the allegation. All residents who needed assistance for showers stated they have received showers on a regular basis and have not miss any showers. All residents stated prior to coming into the facility they recall having a care plan being done. They all stated that the facility regularly checks in on them and checks on their level of care and if there needs and services need to be updated. Seven out of eight staff stated that they regularly check with each other through crossover and through charting notes of any resident changes.
Continued on LIC9099C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20250819172952
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: 04/23/2026
NARRATIVE
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Based on information gathered, there is not sufficient evidence to corroborate the above allegation

Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above allegations Staff does not respond to call button in a timely manner and Staff do not ensure resident's care plan is updated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted a copy of the report was provided to Administrator Austin Morris.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6