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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006421
Report Date: 04/16/2024
Date Signed: 04/16/2024 04:26:03 PM


Document Has Been Signed on 04/16/2024 04:26 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



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: 79DATE:
04/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jeff Stewart - Executive StewartTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit to follow up on an incident report sent to the Regional Office dated April 13, 2024, and received April 15, 2024.

During the visit, LPA Haley conducted interviews with facility staff and briefly spoke with one resident to gather additional information on the incident reported to the Regional Office. During the visit, supporting documents were provided.

As a result of today’s case management visit and the information gathered through staff interviews, and document review, deficiencies will be cited.

Staff interviews and document review confirmed a personal rights violation occurred.

An exit interview was conducted and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/16/2024 04:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: BAYSHIRE YORBA LINDA
FACILITY NUMBER: 306006421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2024
Section Cited
CCR
87468.1(a)(1)

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87468.1 (a)(1) Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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An internal investigation was completed, and the staff involved was terminated. Executive Director Jeff Stewart agrees to schedule an in-service training on Personal Rights of Residents for all staff. Executive Director Stewart will email LPA Haley a detailed breakdown of the topics covered in the in-service training and the sign-in sheet of everyone who attends. Executive Director Stewart will email LPA Haley the date(s) of the scheduled in-service training by the close of business Wednesday, April 17, 2024.
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This requirement is not being met as evidenced by staff interviews and document review that confirmed, Staff 1 (S1) restrained Resident 1 (R1) by grabbing the resident by the arms and confined the resident to their wheelchair. This poses an immediate health and safety risk to residents in care.
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Type A
04/17/2024
Section Cited
CCR87355(e)(1)

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87355 (e)(1) Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department…
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Executive Director Jeff Stewart agrees to have everyone associated with the facility by Thursday, April 18, 2024 at 1:00PM. Anyone who is not cleared and associated at that time will be removed from the schedule until properly cleard and associated. Executive Director Stewart will email LPA Haley a new LIC500 with everyone associated with the facility, no later than Thursday, April 18, 2024 at 1:00PM.
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This requirement is not met as evidenced by document review. Staff 1 (S1) and Staff 2 (S2) have not been properly cleared and associated to the facility prior to working in the facility as required. This poses an immediate health and safety 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.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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