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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604407
Report Date: 08/03/2022
Date Signed: 08/03/2022 10:59:39 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2022 and conducted by Evaluator Elizabeth Hamilton
COMPLAINT CONTROL NUMBER: 08-AS-20220728141817
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: 104DATE:
08/03/2022
UNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Executive Director, Chad Coleman TIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
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9
Staff interfered with resident's sleep.
Staff did not respond to residents call assistance button.
INVESTIGATION FINDINGS:
1
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9
10
11
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13
Licensing Program Analyst (LPA) Elizabeth Hamilton conducted an unannounced complaint investigation at the facility for the above allegations. LPA gained access to the facility, identified herself and met with Executive Director, Chad Coleman. LPA explained the purpose of the visit.

LPA requested and reviewed resident, staff and facility records, interviewed Executive Director and outside sources and briefly toured the facility.

It was alleged on July 27th, 2022, staff interfered with resident's sleep in the Residential Facility for the Elderly (RCFE). Interview with Executive Director revealed resident 1 (R1 – See LIC 811 – Confidential Names List) had never resided at the RCFE. Records reviewed confirmed R1 did not reside in the RCFE.

Continued on next page (LIC 9099C)
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
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 2
Control Number 08-AS-20220728141817
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/03/2022
NARRATIVE
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It was further alleged that in July 2022, staff did not respond to residents call assistance button in the RCFE. Interview with Executive Director revealed R1 had never resided at the RCFE. Facility records reviewed confirmed R1 did not reside at the RCFE.

Further investigation revealed the incident was reported incorrectly under the RCFE and the alleged incidents occurred at the Skilled Nursing area collocated on the larger campus. The California Department of Social Services (CDSS) Community Care Licensing Division (CCLD) does not have jurisdiction over Skilled Nursing Facilities (SNF), therefore the above allegation is determined to be Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. LPA Hamilton will cross-report to the California Department of Public Health.

An exit interview was conducted with Executive Director, Chad Coleman and a copy of this report, LIC 811 and Licensee Appeal Rights (LIC 9058) was provided.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Elizabeth HamiltonTELEPHONE: (619) 929-7590
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2