374604407-8-29-2023-08-AS-SJAB-CV7TL5-20230830144857

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604407
Report Date: 08/29/2023
Date Signed: 08/29/2023 10:15:21 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
01/13/2023 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20230113154243

FACILITY NAME:	BAYSHIRE CARLSBAD		FACILITY NUMBER:	374604407
ADMINISTRATOR:	RAMIREZ, RINAJOY		FACILITY TYPE:	741
ADDRESS:	3140 EL CAMINO REAL		TELEPHONE:	(760) 720-9898
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92008
CAPACITY:	125	CENSUS: 107	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Pamela Talamantes		TIME COMPLETED:	10:57 AM

ALLEGATION(S):

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Facility staff threaten resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted a complaint investigation visit to deliver findings for the above allegation. LPA Domingo met with Resident Service Director Pamela Talamantes and Ariana Ventura Care Coordinator and shared the finding.

The Department’s investigation consisted of record reviews, interviews with staff, and outside sources.

It was alleged that Facility staff threatened Resident 1 (R1) (See LIC811 list of confidential list of identification). LPA Domingo interviewed R1 and R1 did not recall any threatening behavior from staff. Records review of R1's Physician's report confirmed R1 has memory deficits. LPA reviewed the staff schedule and interviewed Staff 1 (S1) S1 and S1 stated that R1 has memory deficits.

[Continued on LIC9099C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230113154243

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BAYSHIRE CARLSBAD	FACILITY NUMBER: 374604407
	VISIT DATE: 08/29/2023

NARRATIVE

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[Continued from LIC9099]

S1 has not observed any staff exhibiting threatening behaviors towards R1. Staff 2 (S2) stated that R1 has episodes of friendly banter that becomes offensive to R1. S2 stated that when interacting with R1, S2 no longer entertains friendly banter. S2 interaction with R1 consists of formal conversation. S3 stated that R1 has not verbalized any incidents of being threatened by staff. Outside Source 1 (OS1) was interviewed by LPA Domingo and there has not been any concerns regarding care of residents. OS1 stated that they do not have any concerns with the facility. Outside Source 2 (OS2) stated that there has been no concerns of staff not providing care to the residents. Outside Source 3 (OS3) was interviewed by LPA Domingo and OS3 stated that there has not been any concerns regarding resident's care. OS3 confirmed that R1 has cognitive deficits.

The Department has investigated the allegation listed above. Based on evidence obtained, including interviews and records reviewed, the above allegation is determined to be unsubstantiated as the Department could not meet the preponderance of the evidence standard. An exit interview was conducted with Resident Service Director Pamela Talamantes, and Ariana Ventura Care Coordinator and a copy of this report and Licensee/Appeals Rights (LIC 9058 03/22) were provide.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

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