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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006421
Report Date: 07/22/2026
Date Signed: 07/22/2026 12:13:11 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
04/17/2024 and conducted by Evaluator Brandon Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240417153456
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: 104DATE:
07/22/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Resident Services Director Mirian Im
Exeucutive Director Kip McMillan		TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not provide appropriate wound care to residents.
Staff did not provide adequate supervision resulting in residents sustaining multiple falls and injuries.
INVESTIGATION FINDINGS:
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On July 22, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Resident Services Director Mirian Im and Exeuctive Director Kip McMillan were present and assisted on today's visit.

During the course of the investigation, the Department conducted interviews with residents, interviews with staff, reviewed and obtained pertinent documents for this complaint. Regarding the allegation, staff did not provide appropriate wound care to residents, the following has been concluded: It was alleged that staff did not provide appropriate wound care to Resident #1 (R1) and Resident #2 (R2). During the course of the investigation, the Department conducted a file review for R1 and observed that R1 moved into the facility on September 3, 2023. The Department reviewed R1's Physician's Report that was completed upon admission to the facility and is dated August 15, 2023. CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
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 7
Control Number 22-AS-20240417153456
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: 07/22/2026
NARRATIVE
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During the course of the investigation, the Department conducted a file review for R4 and observed that R4 moved into the facility on June 21, 2023. The Department reviewed R4's Physician's Report dated May 19, 2023. Per R4's Physician's Report, R4 was diagnosed with dementia, was considered non-ambulatory, and was confused/disoriented. The Department reviewed the facility's progress notes for R4 between the dates of June 21, 2023, through April 30, 2024. The Department observed that during R4's stay at the facility between June 21, 2023, and April 30, 2024, R4 sustained a total of twenty five falls at the facility. The Department observed that R4 was hospitalized as a result of two of the falls. The Department reviewed R4's plan of care between June 21, 2023, and April 30, 2024. The Department observed that the facility stated that they will aim to minimize R4's falls through increased checks as needed. However, there were no other interventions or fall prevention techniques put in place to address this need. The Department also observed that R4 was not reassessed during this period, to determine if he required a higher level of care due to his falls. The Department attempted to conduct an interview with R4 for this allegation, however, R4 was unable to be qualified for an interview due to his cognitive condition.

Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the two allegations listed above. The preponderance of evidence standards has been met; therefore, the above allegations are SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D page. An immediate civil penalty is also being issued in the amount of $500.00. An additional civil penalty is pending determination by the Community Care Licensing Division under Health & Safety Code 1569.49(f). An exit interview was conducted with Resident Services Director Mirian Im and Executive Director Kip McMillan and a copy of the report was provided at time of visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 22-AS-20240417153456
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: 07/22/2026
NARRATIVE
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The Department observed that between May 4, 2023, and May 1, 2024, R1's wound did not improve and only progressed in size. The Department reviewed R1's hospice records between March 28, 2023, and May 1, 2024. Per R1's hospice records dated September 30, 2023, R2 was diagnosed with a stage three pressure ulceration to her buttocks. The Department reviewed R2's plan of care between August 22, 2022 and May 1, 2024. The Department observed that R2's plan of care did not describe her wound care treatment and did not describe in which areas the facility would be assisting R2 with her wound care. The Department conducted five staff interviews. Three out of the five staff interviewed confirmed that R1 and R2 developed wounds while at the facility. Two out of the five staff further corroborated the allegation and reported that improper wound care was provided to R1 and R2. They further stated that staff would not follow R1's or R2's plan of care regarding repositioning. CONTINUED ON LIC9099-C

Regarding the allegation that, staff did not provide adequate supervision resulting in residents sustaining multiple falls and injuries, the following has been concluded: It was alleged that staff did not provide adequate supervision resulting in Resident #3 (R3) and Resident #4 (R4) sustaining multiple falls and injuries. During the course of the investigation, the Department conducted a file review for R3 and observed that R3 moved into the facility on May 4, 2023. The Department observed that R3 passed away on May 4, 2024. The Department reviewed R3's Physician's Report dated September 18, 2023. Per R3's Physician's Report, R3 was diagnosed with dementia, was considered non-ambulatory, and was noted as a fall risk. The Department reviewed the facility's progress notes for R3 between the dates of May 4, 2023, through May 4, 2024. The Department observed that during R3's stay at the facility between May 4, 2023, and May 4, 2024, R3 sustained a total of nineteens falls. The Department observed that R3 was hospitalized as a result of three of the falls. The Department reviewed R3's plan of care between May 5, 2023, and May 4, 2024. The Department observed that the facility stated that they will aim to minimize R3's falls, but did not state what interventions of fall prevention techniques they would be implementing. The Department observed that R3 was not reassessed until April 12, 2024, to determine if she required a higher level of care due to her falls. The Department attempted to conduct an interview with R3 for this allegation, however, R3 was unable to be qualified for an interview due to her cognitive condition.

CONTINUED ON LIC9099-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 22-AS-20240417153456
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: 07/22/2026
NARRATIVE
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The Department conducted an additional four resident interviews. Two out of the four residents were unable to be qualified for an interview due to their cognitive conditions. However, two residents denied the allegation and reported no issues with their incontinence care. The Department conducted five staff interviews. Two out of the five staff corroborated the allegation and reported that there have been multiple times where they have observed residents to be left soiled. However, three out of the five staff interviewed denied the allegation.

Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the one allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Resident Services Director Mirian Im. A copy of the report and appeal rights were provided at time of visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
04/17/2024 and conducted by Evaluator Brandon Lopez
COMPLAINT CONTROL NUMBER: 22-AS-20240417153456

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: 104DATE:
07/22/2026
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Resident Services Director Mirian Im
Executive Director Kip McMillan		TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff left residents in wet briefs for an extended period of time
INVESTIGATION FINDINGS:
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On July 22, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Resident Services Director Mirian Im and Executive Director Kip McMillan were present and assisted on today's visit.

During the course of the investigation, the Department conducted interviews with residents, interviews with staff, reviewed and obtained pertinent documents for this complaint. Regarding the allegation that, staff left residents in wet briefs for an extended period of time, the following has been concluded: It was alleged that staff left Resident #1 (R1) and Resident #2 (R2) in wet briefs for an extended period of time. During the investigation, the Department conducted a file review for R1 and R2. The Department observed that both residents required assistance with incontinence care. The Department attempted to conduct interviews with both R1 and R2, however, both residents were unable to be qualified for an interview due to their cognitive conditions. CONTINUED ON LIC9099-C
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 22-AS-20240417153456
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: 07/22/2026
NARRATIVE
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Per R1's Physician's Report, R1 had a diagnosis of dementia, was considered non-ambulatory, and that R1 did not have a history of skin breakdown. The Department also reviewed a resident care evaluation that was completed by the facility upon R1's admission on September 3, 2023. Per the resident care evaluation, R1 did not have an issues with her skin upon admission and was not receiving any wound care treatment. The Department then reviewed the facility's progress notes for R1 between the dates of September 3, 2023, and May 1, 2024. The Department observed that on September 3, 2023, staff did not observe any skin breakdown on R1. On September 14, 2023, R1 was admitted to hospice. On September 23, 2023, staff noted R1 with an open wound to her left buttocks area. Staff were also advised by hospice to reposition R1 every two hours. On October 19, 2023, R1 was evaluated by wound care specialist due to the wound on her left buttocks area not improving. On February 14, 2024, staff noted that the residents wound to her left buttocks area had progressed to an unstageable wound. Staff noted that R1 was receiving hospice services for her wound three times a week and wound care specialist once a week at this point. The Department observed that by May 1, 2024, R1's wound did not improve. The Department reviewed R1's hospice records between September 14, 2023, and May 1, 2024. Per R1's hospice records dated March 11, 2024, R1 was diagnosed with an unstageable pressure ulceration to her left buttocks. The Department reviewed R1's plan of care between September 3, 2023 and May 1, 2024. The Department observed that R1's plan of care did not describe her wound care treatment and did not describe in which areas the facility would be assisting R1 with her wound care.

The Department conducted a file review for R2 and observed that R2 moved into the facility on September 18, 2022. The Department reviewed R2's Physician's Report that was completed upon admission to the facility and is dated August 22, 2022. Per R2's Physician's Report, R2 had a diagnosis of mild cognitive impairment, was considered non-ambulatory, had a history of skin breakdown, but was not indicated to have an open wounds. The Department then reviewed the facility's progress notes for R2 between the dates of September 18, 2022, and May 1, 2024. The Department observed that on R2 was admitted under hospice on March 28, 2023. On May 4, 2023, staff noted R2 to have an open blister to her buttocks area. On May 11, 2023, staff noted R2 to be bleeding from the open wound to her buttocks area. On July 5, 2023, staff were given instructions by hospice to reposition R2 every two hours to prevent further skin breakdown. On March 12, 2024, staff noted R2's wound to her buttocks area worsened and progressed to a stage three pressure wound. CONTINUED ON LIC9099-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 22-AS-20240417153456
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: 07/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/23/2026
Section Cited
CCR
87464(f)(1)
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87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not evidenced by:
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The Resident Services Director stated that she will review the regulation cited. The Resident Services Director agreed to provide a written statement of understanding of the regulation and will conduct an in service training to all staff regarding monitoring resident's wounds. The Resident Services
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Based on documents reviewed and interviews conducted, the Licensee did not ensure that R1 or R2 received appropriate wound care. Both residents wounds developed/progressed while at the facility. This poses an immediate health and safety risk to persons in care. Civil Penalty Assessed
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Director agreed to provide LPA the written statement and proof training via email or fax by POC due date.
Type A
07/23/2026
Section Cited
CCR
87466
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87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. ...
This requirement was not evidenced by:
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The Resident Services Director stated that they will conduct an in-service training course with all facility staff regarding observing changes in residents’ conditions. The Resident Services Director agreed to provide LPA proof of the training via email or fax by POC date.
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Based on interviews and records reviewed, the licensee did not reassess R3 or R4 to determine if there was a change in condition or more supervision was necessary, due to the amount of falls sustained while at the facility. This posed an immediate health and safety risk to the resident 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: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7