374604407-10-18-2023-08-AS-JBAD-CWR3HK-20231018181603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604407
Report Date: 10/18/2023
Date Signed: 10/18/2023 06:16:16 PM

Document Has Been Signed on 10/18/2023 06:16 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	BAYSHIRE CARLSBAD		FACILITY NUMBER:	374604407
ADMINISTRATOR:	CHAD COLEMAN		FACILITY TYPE:	741
ADDRESS:	3140 EL CAMINO REAL		TELEPHONE:	(760) 720-9898
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92008
CAPACITY:	125	CENSUS: 113	DATE:	10/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Thomas "Ozz" Daynes		TIME COMPLETED:	06:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Amy Rodgers and Juliana Barfield, made an unannounced visit to conduct a required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPAs Amy Rodgers and Juliana Barfield were granted entry into the facility by Executive Director, Thomas Daynes, after identifying themselves and stating the purpose of the inspection. The facility serves 125 non-ambulatory residents, age 60 and above, of which none may be bedridden, and currently has 113 residents in care. There is an approved Hospice Waiver for 27 residents. This is a three-story complex, comprised of three (3) wings and equipped with delayed egress and secured perimeters. LPAs were accompanied by Executive Director, Thomas Daynes during a tour of the facility. Tour was conducted inside and out and included a sample of resident units, the dining area, recreation rooms, and food storage areas. All areas were clean and passageways unobstructed. Signal systems are in place and operational. The last disaster drill was conducted 9/13/2023. A decorative water fixture was present in the inside patio area but patio is not accessible to residents with dementia. According to Executive Director, Thomas Daynes, there are no weapons and/or ammunition stored on the premises. Pull cords were available in each resident unit and were tested for functionality. Delayed egress and secured perimeter doors were also tested for functionality. Resident's room temperatures were within a comfortable range. Continued on 809-C

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Juliana Barfield	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BAYSHIRE CARLSBAD	FACILITY NUMBER: 374604407
	VISIT DATE: 10/18/2023

NARRATIVE

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Continued from 809

Each resident had clean and sufficient bed linens.All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars, and nonskid strips were present in residents’ showers. Hot water temperature in residents’ bathrooms were compliant between 105-120 degrees.

Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. Food menus and activity schedule were posted. Chemicals and cleaning supplies were stored in a locked cabinet. All medications were stored in a locked medication cart, emergency supplies, and medications were labeled and kept in compliance with label instructions.

Staff records reviewed verified that at least one staff member, per shift, has a First Aide/CPR certificate. All staff records had a Criminal Record Clearance, Personnel Record, TB clearance, and Health Screening Report, and required training. Resident files were reviewed and verified that each resident had a current Physician's Report, Resident Appraisal, Needs & Services Plan, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication. Administrator’s certification is current.

LPA reviewed the theft and loss policy and procedures. Conducted a thorough review of Inservice training procedures. Transportation procedures were reviewed and compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs.

An exit interview was conducted. This report was discussed with Executive Director, Thomas Daynes, and a copy of the report along with Licensee/Appeal Rights (LIC 9058) was provided to Thomas Daynes.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Juliana Barfield	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023

LIC809 (FAS) - (06/04)

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