374604784-2-4-2026-08-AS-SJAB-DRTSM9-20260303125933

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604784
Report Date: 02/04/2026
Date Signed: 02/04/2026 12:48:28 PM

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
01/27/2026 and conducted by Evaluator Ramin Hashemi

COMPLAINT CONTROL NUMBER: 08-AS-20260127110332

FACILITY NAME:	BAYSHIRE TORREY PINES		FACILITY NUMBER:	374604784
ADMINISTRATOR:	JEREMY DANENHAUER		FACILITY TYPE:	741
ADDRESS:	13101 HARTFIELD AVE		TELEPHONE:	(858) 259-2222
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92130
CAPACITY:	125	CENSUS: 106	DATE:	02/04/2026
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Resident Services Director, Lizze Mistica		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff Neglect resulted in injury
Staff did not meet the resident's care needs
Staff did not allow visitation

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to open and deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Lizzie Mistica, Resident Services Director (RSD). During the visit LPA collected facility records, conducted a tour of the facility, and interviewed residents and staff.

On 01/27/26 it was alleged "Staff Neglect resulted in injury." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.

Regarding the allegation, "staff neglect resulted in injury," it was alleged that staff's treatment of Resident 1 (R1) created wounds near R1's groin as a result of neglect or insufficient care.

(Continued on LIC9099C, Page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

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 4

Control Number 08-AS-20260127110332

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 TORREY PINES	FACILITY NUMBER: 374604784
	VISIT DATE: 02/04/2026

NARRATIVE

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(Continued from LIC9099, Page 1)
Staff interviews revealed: Facility staff unanimously have not heard of neglect occurring within the facility nor has care that has been provided antithetical to the well-being of a resident; specifically R1. Staff 1 (S1) stated that facility doctors make rounds to all residents in the skilled nursing facility (SNF) multiple times a week and adjust care plans to reflect all resident's current needs. Staff 2 (S2) stated that R1's family helps to ensure that communication and advocation for R1 is met and that the staff and R1's family work together to provide R1 reliable care. Staff 4 (S4) confirmed there were no open or closed wounds that have occurred to R1 while they have been under the care of the SNF.

Outside source interviews revealed: Outside sources unanimously agreed that the care R1 is receiving is satisfactory. Outside Source 1 (OS1) will typically visit R1 on a daily basis and observes the facility staff caring for R1 in a satisfactory manner. Outside source 2 (OS2) stated they have not witnessed any neglect resulting in injury and are satisfied with the care that R1 is receiving. This corroborates staff interviews.

Records Review revealed: R1's care plan dated 05/18/25 states that R1 has a rash service plan which staff will elevate based on observations.

Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.

On 01/27/26 it was alleged "staff did not meet the resident's care needs." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.

Regarding the allegation, "staff did not meet the resident's care needs," it was alleged that staff are not adjusting care needs of the resident in a timely or safe manner.

Staff interviews revealed: Facility staff unanimously agreed that the care that R1 has been provided has evolved to meet their needs as treatment has progressed. S4 stated that while R1 was receiving treatment in the SNF for an infection, R1 developed a rash near the perinatal area due to excessive diarrhea which can commonly occur as a result of antibiotic treatment. S1, S3, and S4 all stated separately that care staff responded quickly and efficiently to treat R1.
(Continued on LIC9099C, Page 3)

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20260127110332

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 TORREY PINES	FACILITY NUMBER: 374604784
	VISIT DATE: 02/04/2026

NARRATIVE

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(Continued from LIC9099C, Page 2)
Outside source interviews revealed: OS1 and OS2 advocate for R1 if they feel R1 needs more care from the facility. OS1 stated that with the recent rash, facility staff responded quickly with: treatment, visits from medical staff, and medication that has met the needs of R1's care plan. OS1 has stated they have no concerns for the facilities timeliness or approach to treating R1. OS2 stated that the rash that has occurred from treatment is common for R1 and the facility staff are quick to address R1's needs when they arise. Outside source interviews corroborate staff interviews.

Records review revealed: R1's Physician's report dated 05/18/25 identified R1 with chronic heart failure and mild cognitive impairment. A SNF care note dated 03/31/2025 stated that R1 has been identified with Crohn's disease. R1's care plan dated 05/18/25 includes skin checks when performing ADL services and a dedicated rash service plan.

Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.

On 01/27/26 it was alleged "staff did not allow visitation." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.
Regarding the allegation, "staff did not allow visitation," it was alleged that staff refuse a special visitor to visit R1 while they stay in Assisted Living (AL) or the Skilled Nursing Facility (SNF).

Staff interviews revealed: Staff demonstrated knowledge of visitation rights and resident rights. S1 stated they were aware of the legal situation involving a special visitor of R1. According to S1, S2, and S3, the special visitor of R1 has been denied visitation to R1 through a judge and court order. S1 and S2 stated they have talked to R1's family lawyers, to the court, and to the facility's legal team to ensure that R1's visitation rights are upheld. Facility staff have had to remind the special visitor for R1 of the obligations they must follow in order to visit R1, as a result of the court order.

Outside source interviews revealed: Outside sources have confirmed that R1's visitation rights have been followed based on the legal restrictions in place. OS1 stated there have been times when the special visitor has not followed the legal provisions of the restraining order when it came to visiting R1 in the past. This corroborates staff interviews.
(Continued on LIC9099C, Page 4)

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20260127110332

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 TORREY PINES	FACILITY NUMBER: 374604784
	VISIT DATE: 02/04/2026

NARRATIVE

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(Continued from LIC9099C, Page 3)
Records review revealed: R1's special visitor did not appear at the facility through the time frame the restraining order was active and began visiting again later with a court ordered supervisor.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with RSD Lizzie Mistica, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Ramin Hashemi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

LIC9099 (FAS) - (06/04)

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