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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604407
Report Date: 10/11/2022
Date Signed: 10/11/2022 02:02:27 PM


Document Has Been Signed on 10/11/2022 02:02 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:BAYSHIRE CARLSBADFACILITY NUMBER:
374604407
ADMINISTRATOR:RAMIREZ, RINAJOYFACILITY TYPE:
741
ADDRESS:3140 EL CAMINO REALTELEPHONE:
(760) 720-9898
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:125CENSUS: 110DATE:
10/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Pam Talamantes, Residence Services DirectorTIME COMPLETED:
10:18 AM
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Licensing Program Analyst (LPA) Daniela Huerta and Interim Assistant Program Administrator (IAPA) Icela Estrada conducted an unannounced case management visit to follow up on two self-reported incident reports, received by the Regional Office on 7/07/22 and 7/20/22. LPA and IAPA identified themselves, stated the purpose of the visit, and met with Chad Coleman, Executive Director. During the visit, Pam Talamantes, Residence Services Director arrived and met with LPA and IAPA.

The facility self-reported two medication errors at the facility.

On 7/06/2022 Resident # 1(R1) was given medication that belonged to Resident # 2 (R2) by Staff #1. R1 was given the following medications: Aspirin 81mg, Calcium 600mg, Colace 100mg, Escitalopram 5mg, Miralax 17GM, Spironolactone 25mg, Trospium Chloride 20mg, Tylenol 325mg, Vitamin D3. There was no adverse effects due to the medication error. The Department verified that the licensee cross-reported to the Primary Care Physician (PCP) and responsible party (RP).

On 7/18/2022 Staff #2 did not administer medication to 26 residents. On 7/18/2022 at around 4:00 PM, Staff #3 noticed the medication bubble packs not popped on 7/18/2022 for the day shift. Upon further investigation by Staff #4, it was discovered that Staff #2 electronically signed for medication administration for all (26) residents in the Memory Care community, however, did not pop any of the medications out of the bubble pack for that day. Staff #2 was placed on suspension that same day, and after facility concluded their internal investigation Staff #2 was terminated on 08/01/2022. The Department verified that the licensee cross-reported to the PCPs and RPs for the 26 residents.

A review of records revealed the licensee had a local pharmacy provide on site training to all medication technicians on July 15 and July 27, 2022 to address both incidents.

A deficiency is cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 1, and is noted on the attached LIC802-D.

An exit interview was conducted and a copy of this report and Appeals Rights (LIC 9058 01/16) were provided to Pam Talamantes, and her signature on this form, acknowledges receipt of these rights.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniela HuertaTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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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Document Has Been Signed on 10/11/2022 02:02 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2022
Section Cited

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87465 Incidental Medical and Dental Care
(c)(2) Once ordered by the physician, the medication is given according to the physician's directions.


This requirement is not met as evidence by:
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Based on interview and record review, the licensee did not give medications in accordance to the physician's orders in 27 of 96 persons in care [R1-R27] which posed a potential Health or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniela HuertaTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
LIC809 (FAS) - (06/04)
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