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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006421
Report Date: 03/26/2024
Date Signed: 03/26/2024 12:09:55 PM

Document Has Been Signed on 03/26/2024 12:09 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:
740
ADDRESS:17803 IMPERIAL HWYTELEPHONE:
(714) 777-9666
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 114CENSUS: 82DATE:
03/26/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marie Stern - Director of Operations/ Hrag Bekerian - Administrator TIME COMPLETED:
11:45 AM
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an announced visit to conduct a pre-licensing visit. LPA was greeted and granted entry into the facility by Marie Stern, Director of Operations and Hrag Bekerian Administrator and explained the reason for the visit. An initial application was submitted on 08/25/2023 with a fire clearance for 104 non-ambulatory and 10 bedridden granted on 02/14/2024.

LPA Mendivil and Director of Operations Marie Stern and Administrator Bekerian toured the facility.

The facility is a two story building with Assisted Living taking up two levels and Memory Care occupying the rear of the first floor. Assisted Living has 90 bedrooms and currently has 60 residents occupying rooms. Memory Care has 23 bedrooms with 22 residents occupying the rooms. The first level on assisted living contains staff offices, dining room, activity room, and beauty room.

At 9:15 AM, LPA toured the entire community, interior and exterior, including a sampling of resident apartments. Hot water in resident apartments tested between 107.1-119 degrees F. Fire extinguishers were mounted and charged. Smoke detectors were centrally wired throughout and have been checked by the fire department on 03/18/2024. Carbon monoxide detectors were observed and are operational. There are E-Vac chairs present in all stairwells. There was a locked medication room for both assisted living and memory care for residents who need medication management. There were a number of locked janitorial closets for storage of toxins and cleaning equipment. An emergency call system was in place in each apartment and tested.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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
VISIT DATE: 03/26/2024
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First aid kits are located in the medication room and memory care. Kitchen was stocked with food to meet the regulatory amounts. LPA observed activity calendars posted, menus and activities available. There is a country kitchen on the second floor, tv room, salon, laundry room and activity room. LPA observed the medications and med-techs providing medications in a locked cart to residents.
Facility is ready to be licensed. Component III completed.


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC809 (FAS) - (06/04)
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