306006421-5-5-2025-22-AS-LMOA-DHG8UH-20250608224934

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006421
Report Date: 05/05/2025
Date Signed: 05/05/2025 05:07:24 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
02/11/2025 and conducted by Evaluator Edward Kim

COMPLAINT CONTROL NUMBER: 22-AS-20250211134439

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: 84	DATE:	05/05/2025
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Executive Director- Austin Morris		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility does not have sufficient staff in the memory care unit.
Facility failed to take the appropriate precautions to safeguard resident's property.
Facility failed to ensure adequate personal care supplies are available for residents.

INVESTIGATION FINDINGS:

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On May 5, 2025, Licensing Program Analysts (LPAs) Edward Kim and Jessica Cho conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Executive Director (ED) Austin Morris and explained the purpose of today’s visit.

The investigation consisted of the following: On February 13, 2025, LPA Kim toured the facility with ED Austin Morris. LPA Kim requested and obtained copies of the resident and staff rosters, resident records which include the Physician’s Reports, Appraisal/Needs and Services Plans, and other pertinent records for nine residents, Residents #1-#9, (R1-R9). LPA Kim interviewed four staff, Staff #1-#4 (S1-S4), and seven residents, (R1-7).

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: 05/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025

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-20250211134439

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: 05/05/2025

NARRATIVE

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Allegation: Facility does not have sufficient staff in the memory care unit.

Based on LPA Kim’s observations conducted on February 13, 2025, there were twenty-two memory care residents present and four staff providing direct care. LPA observed residents’ needs were met during the visit.

Based on interviews conducted, seven out of seven residents and two out of four staff denied the allegation. The remaining two out of four staff confirmed that the facility does not have sufficient staff in the memory care unit. One staff explained each shift is sufficient to meet the care and needs for all the memory care residents. There are four caregivers with one Medication Technician (MT) per shift for AM and PM. There are two caregivers and one MT during the NOC Shift.

Based on records review, the facility has twenty-two memory care residents per the Facility Register and twenty-three staff providing care to resident in memory care unit per the Staff Schedule. The facility staff schedule shows morning shift is from 6:00 AM to 2:00 PM with two staff, and an additional staff is staggered from 10:00 AM to 6:00 PM with one staff. The afternoon shift is from 2:00 PM to 10:00 PM with two staff and an additional staff from 6:00 PM to 6:00 AM. Based on the schedule, there are four staff work as deemed necessary. Per review of the plan of operations there isn’t a required number of staff.

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

Allegation: Facility failed to take the appropriate precautions to safeguard resident's property.
It is alleged the facility takes supplies from other residents if they run out. It is alleged that the management at the facility has instructed staff to take supplies from other residents if they run out. It is alleged that families have started to complain because they notice the supplies they purchase for their family member runs out too quickly and suspect they are being used for other residents in care.

Based on LPA’s observation, the facility stores memory care supplies are in a storage room. Each memory care resident has their own cubby with their names written on the hygiene supplies. During the visit, LPA Kim did not witness a situation where staff took supplies from one resident to be used for another resident in the memory care unit. LPA Kim examined multiple bathrooms and did not see any items marked with another person’s name nor any residents saying that those hygiene items belonged to somebody else.
Continued on LIC9099C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20250211134439

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: 05/05/2025

NARRATIVE

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Based on interviews conducted, seven out of seven residents and two out of four staff denied the facility failed to take appropriate precautions to safeguard resident’s property. The remaining two out of four staff have confirmed that the facility failed to take the appropriate precautions to safeguard resident’s property. Six out of seven residents stated they have not heard or observed any resident’s supplies or property been taken without permission. One resident stated they have observed in their room that low value items were moved or taken. That same resident stated they have not observed any staff or resident take any hygiene supplies from one room to the next. The resident stated the facility has taken the appropriate precautions to safeguard their property. Two out of the four staff stated that they do not know of any staff who would take and use supplies from one resident supplies for another and management has not instructed staff to take supplies from other residents. One staff stated that families have complained about incontinence supplies running out quickly, but explained that these supplies often get used faster by the resident than the family expects.

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

Allegation: Facility failed to ensure adequate personal care supplies are available for residents.

It is alleged that the facility does not have sufficient hygiene supplies for residents. It is alleged that the facility runs out of hygiene supplies that are needed for residents such as wipes, toothpaste, deodorant, and towels. It is alleged that staff at the facility have had to purchase hygiene supplies on their own for residents or else they would not have any.

Based on observation, LPA Kim observed the memory care supplies in a storage room in the facility. Each memory care resident had a cubby with their names listed on their items. Additional supplies are also stored in the second floor in additional storage rooms providing all necessary care supplies.

Based on interviews seven out of seven residents and two out of four staff denied the facility failed to ensure adequate personal care supplies are available for residents. The remaining two out of four staff confirmed facility failed to ensure adequate personal care supplies are available for residents. All residents, stated the facility provides toilet paper, paper towels, and soap for all residents. One out of four staff stated that all hygiene supplies such as toothbrush, toothpaste, shampoo, and incontinence supplies are provided by the resident’s responsible party or hospice and is acknowledged in the admissions agreement.
Continued on LIC9099C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20250211134439

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: 05/05/2025

NARRATIVE

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Based on record reviews, the Admission Agreement states that the facility assumes that the residents provide their own supplies for personal care and hygiene such as hand soaps, towels, etc. However, if they are unable to provide such supplies, the facility will provide the residents with basic personal items for an additional fee. In Appendix A, personal items are listed with a charge of it being individually priced. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview was conducted, and a copy of the report was provided to Executive Director Austin Morris.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025

LIC9099 (FAS) - (06/04)

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