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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604407
Report Date: 06/02/2021
Date Signed: 06/03/2021 08:47:16 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BAYSHIRE CARLSBADFACILITY NUMBER:
374604407
ADMINISTRATOR:HIGHTOWER, SASHAFACILITY TYPE:
741
ADDRESS:3140 EL CAMINO REALTELEPHONE:
(760) 720-9898
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:125CENSUS: 76DATE:
06/02/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Executive Director, Sasha HightowerTIME COMPLETED:
05:10 PM
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Licensing Program Manager (LPM), Alexandre Vo, conducted an announced Pre-Licensing/Component III. LPM identified himself to Executive Director, Sasha Hightower, and explained the purpose of the visit which was to evaluate Title 22 compliance for change of ownership. The facility plans to serve elderly residents, ages 60 and over. The Fire Clearance was granted on February 16, 2021. Facility is approved for 125 non-ambulatory residents of which 15 may be bedridden. Hospice Waiver for 17. The Fire-Clearance is also approved for delayed egress.

An inspection of the facility was conducted inside and out. A sample of eight resident rooms were observed. Bathrooms are equipped with toilets, hand washing and bathing facilities which are sanitary and in operating condition. Water temperatures ranged from 106 degrees to 113 degrees F for the resident and common area bathrooms. All lighting fixtures and facility windows were operable and in good condition. A night-light was present in the hallway leading to the restroom.

Outdoor and indoor passageways were free from obstructions. Fire extinguishers were affixed with current tags. Smoke and carbon monoxide detectors were present and operational. There were no pools or other bodies of water observed on the premises. Locked cabinets and storage areas were identified to store toxic substances, knives, and medication. Hazardous items were stored such that they were inaccessible to residents. Per Executive Director, no weapons or ammunition are or will be stored at the facility.

LPM observed facility accommodations including food supplies, medication storage, first aid kit as well as toiletries and linens. Required CCLD postings were present. LPA discussed the RCFE Comp III with Executive Director Hightower for continuing operational requirements, record keeping, reporting requirements and physical plant compliance. Executive Director's Administrator Certification is current through January 20, 2022.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre VoTELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BAYSHIRE CARLSBAD
FACILITY NUMBER: 374604407
VISIT DATE: 06/02/2021
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Technical assistance was provided in the areas observed and listed on the Advisory Notes. The Executive Director was advised that the report is pending management approval. An exit interview was conducted with Executive Director. A copy of this report along with the licensee Appeal Rights (LIC 9058 01/16) will be provided via email. An electronic email read receipt confirms the documents were received.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Alexandre VoTELEPHONE: (619) 385-7506
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
LIC809 (FAS) - (06/04)
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