306006421-7-16-2026-22-AS-LMOA-DX52YS-20260819174913

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006421
Report Date: 07/16/2026
Date Signed: 07/16/2026 03:54:09 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
09/11/2025 and conducted by Evaluator Edward Kim

COMPLAINT CONTROL NUMBER: 22-AS-20250911123217

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: 105	DATE:	07/16/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Resident Services Director		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff did not meet a resident's incontinence needs
Staff are not properly trained

INVESTIGATION FINDINGS:

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On July 16, 2026, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Resident Services Director (RSD) Mirian Im and explained the purpose of the visit. RSD Im contacted Interim Administrator (ADMIN) Chad Coleman and LPA Kim explained the purpose of the visit. Interim ADMIN Coleman stated he could not attend today's visit and RSD Im could sign on behalf of the facility.

The investigation consisted of the following. LPA Kim toured the facility. LPA requested and obtained copies of the resident and staff rosters. LPA requested copies of four residents service records which include Physician’s Report, Appraisal/Needs and Services Plan, hospice care plans, admission agreements, facility progress notes, and other document 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: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

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 3

Control Number 22-AS-20250911123217

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: 07/16/2026

NARRATIVE

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Allegation: Staff did not meet a resident's incontinence needs.
It is alleged for Resident #2 they were complaining about how staff was not handling the Purewick correctly and that led to labial bleeding.

Based on record review, R2’s Physician Order dated September 29, 2025, that the family will provide the PureWick. It states on the physician order that the PureWick will be applied and removed in the morning in a clean canister after each use. It is also states the collector tube will be replaced every 60 days. There is no order from the doctor to indicate this was to be applied by facility staff. R2’s Physician Order dated October 23, 2025, the PureWick system was discontinued due to itchiness. There is nothing on the physician’s order that states the facility were to apply or assist in using the PureWick with R2. R2’s Physician’s Report dated June 11, 2025, stated that R2 did not have bowel impairment or bladder impairment. Progress Notes dated on October 23, 2025, noted blood on the Pure Wick Insert, and stated R2 did not complain of pain and no more blood was noted on a later routine check.

Based on interviews conducted, four out four staff and one resident denied the allegation. R2 stated that they used the PureWick for a short period because the doctor recommended it. They stated the liked the idea but the issue was it kept slipping out because they were moving too much when they were sleeping. They stated they don't recall experienced any injury or bleeding. When shown a photo of what was in the PureWick that made it red, they stated they had no idea. After trying for a short period of time, R2 stated they stopped using it because it made them feel uncomfortable. Four staff stated that R2 took care of it themselves in applying the PureWick to themself. The four staff do not recall if they cleaned it regularly, but would assist if the resident asked to help clean the product as requested.

Based on the information gathered, there is no sufficient evidence to corroborate the above allegation. The facility did not need to meet the incontinence needs for the PureWick based on the Physician’s Order. There is no order that specifies that the facility is to apply and remove the PureWick for R2.

Allegation: Staff are not properly trained
It is alleged that there is no training for care staff for handling R1’s CPAP and R2’s PureWick.
Based on interviews conducted, four out of four staff and six out of six residents denied the allegation. All four staff stated that the Nocturnal (NOC) shift would help R1 place the CPAP machine mask on R1, and the Morning (AM) shift would help remove the CPAP machine mask off of R1 as indicated in the Physician’s
Continued on LIC9099C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20250911123217

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: 07/16/2026

NARRATIVE

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order. All four staff stated that R2 placed the PureWick on themselves and would assist in cleaning the device if requested. There was no training records for the CPAP and PureWick because training was not required for either. S2 and S3 stated that they had training for CPAP from a different facility, but it probably wasn’t in the records.

Based on record review, R1’s Physician Order dated August 23, 2023, stated the facility would help assist the resident with putting on CPAP in the PM and removing the CPAP in the AM. R2’s physician order states that the PureWick will be applied and removed in the morning in a clean canister after each use. It is also states the collector tube will be replaced every 60 days. There is no order from the doctor to indicate this was to be applied by facility staff. There are no training records for CPAP and PureWick as verified by staff interviews. S2’s and S3's file did not have CPAP training in their file from their previous facility.

Based on the information gathered, there is no sufficient evidence gathered to corroborate the above allegation. It is determined that all staff did not need training based on R1’s and R2’s Physician’s order. For R1, staff would assist in putting on and removing the CPAP mask. For R2, there is no instructions from the physician for the staff to help apply the PureWick or remove the PureWick.

Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegations staff did not meet a resident's incontinence needs and staff are not properly trained. 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 Resident Services Director Mirian Im.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC9099 (FAS) - (06/04)

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