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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006421
Report Date: 05/05/2025
Date Signed: 05/05/2025 04:49:58 PM

Document Has Been Signed on 05/05/2025 04:49 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BAYSHIRE YORBA LINDAFACILITY NUMBER:
306006421
ADMINISTRATOR/
DIRECTOR:		COLEMAN, CHADFACILITY TYPE:
741
ADDRESS:17803 IMPERIAL HWYTELEPHONE:
(714) 777-9666
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 114CENSUS: 84DATE:
05/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Executive Director- Austin MorrisTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On May 5, 2025, at 8:00 AM, Licensing Program Analysts (LPAs) Edward Kim and Jessica Cho conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs met with Resident Service Director (RSD) Miriam Im. RSD Im called over the phone Executive Director (ED) Austin Morris who stated they would arrive to join the physical tour and LPA Kim explained the purpose of the visit.

The facility is licensed to operate for one hundred fourteen (114) non-ambulatory, of which ten (10) may be bedridden, and maintains a hospice waiver for twenty (20) residents. The facility is a two-story structure, which consists of the following: one hundred twelve (112) resident bedrooms, thirteen (13) offices, one hundred sixteen (116) bathrooms, waiting area, hair salon, first floor activity area, second floor activity area, memory care dining room, main dining room, gym, kitchen, memory care courtyard, and two outdoor areas with outdoor covered patio.

LPA Kim toured indoor and outdoor physical plant with RSD Im. ED Morris joined the tour around 9:00 AM. There is a fountain in one of the outdoor areas. All rooms were inspected. Beds and bedding supplies were in good condition with adequate lighting and refrigerator as well as storage for each resident’s personal belongings were observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The following resident apartments were inspected: 103, 107, 119, 140, 151, 156, 235, 260, and 274. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 106.7 degrees F and 114.2 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility.
Evaluation Report Continues on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BAYSHIRE YORBA LINDA
FACILITY NUMBER: 306006421
VISIT DATE: 05/05/2025
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During the visit, LPA Kim observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and inaccessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food and supplies are stored in the kitchen and in a storage room closet next to the kitchen. Emergency water is stored in a storage closet in Skilled Nursing across from room 183 and room 184. A working telephone (714) 844-0967 remains available.

LPA Kim reviewed the facility’s plan of operation, emergency and disaster plan, and fire/safety drill log. The facility last conducted an Emergency Drill on April 28, 2025. The facility has fire extinguishers that are charged, and they were all serviced on October 4, 2024. Smoke detectors, and carbon monoxide detectors were operable and tested by CAL Building Systems on April 22, 2025. First Aid was maintained and contained all the necessary elements. Evidence of Liability insurance is effective on November 1, 2024, and expires on November 1, 2025.

LPA Kim conducted an audit of nine (9) resident files (R1-R8), eight (8) staff files (S1-S8). LPA conducted six (6) resident interviews, four (4) staff interviews, audited medications for the nine residents.

LPA discussed the following: to ensure that the medications are given according to the physician’s directions and Tuberculosis (TB) test result is maintained for S1.

Based on today’s visit, deficiencies are being cited as per the Title 22 Division 6 Chapter 8 of California Code of Regulations (CCR).

An exit interview was conducted, and a copy of this report and appeal rights were provided to Executive Director Austin Morris.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/05/2025 04:49 PM - It Cannot Be Edited


Created By: Edward Kim On 05/05/2025 at 04:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BAYSHIRE YORBA LINDA
FACILITY NUMBER: 306006421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(2)
87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, record review, and interview, four (4) out of nine (9) residents, R1, R2, R3, and R4 medications were not given according to physician’s directions which poses a potential health, safety, and/or personal rights risk to residents in care.
POC Due Date: 05/19/2025
Plan of Correction
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Licensee states they will submit proof of the current and accurate Medication Order Summaries for R1, R2, R3, and R4, and an acknowledgement of understanding to CCLD via email to Edward.kim@dss.ca.gov by POC due date May 19, 2025.
Type B
Section Cited
CCR
87411(f)
87411 (f) Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test… A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, record review, and interview, one out of eight staff, S1 did not have valid TB test in their records, which poses a potential health, safety, and/or personal rights risk to residents in care.
POC Due Date: 05/19/2025
Plan of Correction
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Licensee states they will submit proof of the current and accurate TB test for S1, and an acknowledgement of understanding to CCLD via email to Edward.kim@dss.ca.gov by POC due date May 19, 2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Edward Kim
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2025


LIC809 (FAS) - (06/04)
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