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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604407
Report Date: 07/21/2023
Date Signed: 07/21/2023 05:58:37 PM


Document Has Been Signed on 07/21/2023 05:58 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:CHAD COLEMANFACILITY TYPE:
741
ADDRESS:3140 EL CAMINO REALTELEPHONE:
(760) 720-9898
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:125CENSUS: 111DATE:
07/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Executive Director Thomas "Ozz" DaynesTIME COMPLETED:
06:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Thomas "Ozz" Daynes.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received 06/20/2023). According to the LIC624, on 06/16/2023, an error by Staff #1 (S1) led to Resident #1 (R1) being given and ingesting doses of two (2) medications which were not prescribed to them. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. These unauthorized doses did not result in R1 experiencing adverse symptoms.

During today’s visit, LPA performed a brief facility tour and welfare check, finding that R1 was safe, alert, and talkative. LPA reviewed pertinent records and interviewed R1 and relevant staff. LPA also sat in as an observer for a portion of the facility’s Resident’s Council Meeting.

Interviews and records showed: R1 required staff assistance with storing and taking their prescribed medications. The above medication errors were timely reported via phone to R1’s physician and R1’s responsible person. Licensee followed the physician’s instructions (i.e., to keep observing R1 and measuring their vital signs). Licensee increased observation of R1 over the next 72 hours. R1 did not present any adverse symptoms during that time. Following the incident, Licensee: a) individually counseled and retrained S1 on accurate medication pass procedures, and b) retrained their larger medication technician team on accurate medication pass procedures.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: 07/21/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

A preponderance of evidence exists showing that during the incident in question, Licensee did not assist R1 with medications as prescribed by R1's doctor. One (1) deficiency is thus cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPA also issued one (1) Technical Violation regarding Reporting Requirements (refer to the attached LIC 9102-TV).

An exit interview was conducted with Daynes, to whom a copy of this report, the LIC 809-D, the LIC 9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/21/2023 05:58 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: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2023
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:
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Per staff interview: following the incident, Licensee individually counseled and retrained S1, and then retrained its larger medication technician team on accurate medication pass procedures. Licensee agreed to E-mail to LPA the following by the POC due date: a) evidence of individual counseling/retraining with S1, and b) the team training sign-in sheet.
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Based on records and interviews, the licensee did not assist 1 of 111 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
LIC809 (FAS) - (06/04)
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