306006421-4-23-2026-22-AS-LMOA-DTN4PU-20260430191719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006421
Report Date: 04/23/2026
Date Signed: 04/23/2026 05:29:35 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
02/12/2025 and conducted by Evaluator Edward Kim

COMPLAINT CONTROL NUMBER: 22-AS-20250212084002

FACILITY NAME:	BAYSHIRE YORBA LINDA		FACILITY NUMBER:	306006421
ADMINISTRATOR:	COLEMAN, CHAD		FACILITY TYPE:	741
ADDRESS:	17803 IMPERIAL HWY		TELEPHONE:	(714) 777-9666
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	114	CENSUS: 95	DATE:	04/23/2026
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Administrator Austin Morris		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff mismanaged resident's medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Edward Kim conducted an unannounced subsequent complaint visit to deliver complaint investigation findings. LPA met with Administrator (ADMIN) Austin Morris and explained the purpose of today’s visit.

The investigation is as follows: On February 13, 2025, LPA Kim initiated the complaint investigation and conducted a health and safety inspection with ADMIN Austin Morris. LPA Kim obtained copies of resident records for review which include the following: Resident/Staff Rosters, Staff Schedule, Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans/Reappraisal, Medication Administration Records, Incident reports, home healthcare records, and hospital 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: 1 of 4

Control Number 22-AS-20250212084002

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 mismanaged resident's medication
It is alleged that facility did not monitor R1’s medication upon transfer from the Skilled Nursing facility and discontinued R1’s insulin.

On February 10, 2025, around 8:00 AM, R1 did not respond to staff’s verbal or tactile stimuli. R1 was breathing normally and unlabored. R1’s blood sugar level was at 978, blood pressure at 72/47, and a heart rate of 78, 9-1-1 was called and R1 was taken to the hospital. R1 was diagnosed with Diabetic Ketoacidosis (DKA), Severe Anemia, and Seizure.

Based on the investigation, record review shows R1 was admitted to the Memory Care unit of the facility on February 4, 2024. Per Discharge Summary from Providence Skilled Nursing facility dated February 3, 2025, Lantus Solostar was noted with 4 refills with start date February 3, 2025, and without an end date.

Per review of R1’s Medication Administration Record (MAR), the start date for Lantus Solostar was February 4, 2025, and discontinued date on February 5, 2025. R1 did not receive any Lantus Solostar per interviews with four out of four staff. However, there is no physician’s order for R1 to discontinue the Lantus Solostar.

During the interviews, four out of four staff and four out of four witnesses corroborated with the allegation that staff mismanaged resident's medication due to lack of communication between the facility and Skilled Nursing Facility regarding R1’s discharge medications. S2 stated the facility did not administer the Lantus Solostar as it was marked as “discontinued” (DC) per Order Summary report. W4 stated that Lantus Solostar was circled to confirm that the medication needed to be continued. W3 and W4 also confirmed that on page 2 of Providence discharge summary dated February 3, 2025, lists Lantus Solostar as a continued medication. W3 stated that R1 has uncontrollable diabetes which could go extremely high or low without proper medication. All witnesses and staff confirmed that the Lantus Solostar medication was mismanaged causing R1’s hospitalization. R1 was diagnosed with Diabetic Ketoacidosis, severe anemia, and seizures.

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: 2 of 4

Control Number 22-AS-20250212084002

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 through interview and record review, the preponderance of evidence standard has been met, therefore, the allegation Staff mismanaged resident’s medication was found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6 Chapter 8. An Immediate Civil Penalty is being assessed in the amount of $500. See the attached LIC421IM. A Civil Penalty is pending determination as per Health and Safety Code 1548(c)(1).

An exit interview was conducted, and a copy of this report including the LIC421, LIC811, and the appeal rights were 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: 3 of 4

Control Number 22-AS-20250212084002

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 A 04/24/2026 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4) A plan for incidental medical ... shall be developed by each facility. The plan shall encourage routine medical ... for assistance ... by compliance with... The licensee shall assist residents with self administered medications as needed. This requirement is not met evidenced by:	1 2 3 4 5 6 7	Licensee states they will send a copy of an in service training on the policy and procedures regarding medication knowledge required to safely assist with prescribed medications which are self administered prior to admittance to the facility to CCLD via email to edward.kim@dss.ca.gov by POC due date
	8 9 10 11 12 13 14	R1 missed prescribed insulin medication from 2/4/2025 to 2/10/2025, due to staff mismanagement of R1’s medications, which resulted in hospitalization. R1 was subsequently diagnosed with diabetic ketoacidosis, severe anemia, and seizures. This poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14	April 24, 2026. An Immediate Civil Penalty for $500 is assessed during the visit.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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)

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