306006421-5-29-2024-22-AS-LMOA-D5SVW6-20240531164726

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006421
Report Date: 05/29/2024
Date Signed: 05/29/2024 12:11:58 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/23/2024 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240523163241

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: 74	DATE:	05/29/2024
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Chad Coleman		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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The Administrator is not present in the facility.
The Administrator is not qualified to be an Administrator.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding a complaint that was filed May 23, 2024. LPA Haley was greeted by staff and explained the reason for the visit.

Regarding the allegations above, 2 of 2 staff members provided evidence that contradict the complaint allegations. Staff 1 (S1) is the current Administrator and has a current Administrator’s certificate. S1 served as an Administrator in a previous RCFE from 2021 – 2024. S1 says scheduling fluctuates, so sometimes S1 is in the building once a week or sometimes three times a week.

According to S1, Staff 2 (S2) is designated to serve as the backup Administrator, and Staff 3 (S3) is a qualified Administrator with a current Administrator Certificate. S1 explained, S3 can also serve as a backup Administrator and will be the designated backup Administrator when S2 moves into the role as Administrator. S2 is currently a Nursing Home Administrator and has completed and submitted all the training requirements to become an RCFE Administrator.
Continued on LIC9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240523163241

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 05/29/2024

NARRATIVE

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According to S2, the Administrator’s (S1) hours vary, “It varies. Sometime (S1) can be here 10-15 hours a week… sometimes more, sometimes less.” S2 said S1 was in the facility last week.

Based on the information gathered during the investigation through interviews, observations, and document review, the allegations mentioned above are deemed Unfounded, meaning the allegations are false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024

LIC9099 (FAS) - (06/04)

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