374604784-5-1-2026-08-AS-AGOH-DTKV2U-20260428160343

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604784
Report Date: 04/28/2026
Date Signed: 05/01/2026 09:29:34 AM

Document Has Been Signed on 05/01/2026 09:29 AM - 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 TORREY PINES		FACILITY NUMBER:	374604784
ADMINISTRATOR/ DIRECTOR:	JEREMY DANENHAUER		FACILITY TYPE:	741
ADDRESS:	13101 HARTFIELD AVE		TELEPHONE:	(858) 259-2222
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92130
CAPACITY: 125		CENSUS: 104	DATE:	04/28/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Executive Director Jeremy Danenhauer and Resident Services Director Lizzie Dela Fuente		TIME VISIT/ INSPECTION COMPLETED:	04:10 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 Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to concierge CJ Isidro, who allowed LPA entry. LPA then met with Executive Director Jeremy Danenhauer and Assistant Resident Services Director Agnes Tuazon. Note, LPA did step out for lunch from 12:30-1:30pm. The facility's license shows a maximum capacity of one-hundred-and-twenty-five (125) non-ambulatory residents, thirty-nine (39) of which may be bedridden. Per the fire clearance, all bedrooms are approved for bedridden occupancy. Additionally, the facility is approved for a hospice waiver for twenty-five (25) and delayed egress in the Memory Care unit. During today’s inspection there were one-hundred-and-four (104) residents in care, with thirteen (13) currently on hospice. LPA and Executive Director Danenhauer toured the interior and exterior of the facility and inspected common areas and a sampling of occupied and unoccupied resident rooms. Director of Mental Health Care David Kraft joined for the tour of the Memory Care unit. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. [Continued on LIC 809-C]

NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 TORREY PINES	FACILITY NUMBER: 374604784
	VISIT DATE: 04/28/2026

NARRATIVE

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[Continued from LIC 809]

LPA tested hot water temperatures at taps accessible to clients. A bathroom sink in a resident's unit on the 3rd floor read at 124.9F and another 3rd floor unit tested at 124.3F. LPA additionally tested a sink on the first floor which read at 122F. Maintenance staff went to adjust the water heater and LPA tested the water again and third floor read at 108.7F. One Type A deficiency was issued for the hot water being above the approved range of 105F to 120F. The facility does maintain daily water temperature logs and in the week leading up to today, recorded temperatures routinely ranged from 114-116F.

Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were stored in the main kitchen which is occupied by staff during the day (kitchen locked at night). The kitchen maintained a system to track resident modified diets and allergies.

No toxic chemicals or poisons were accessible to clients at risk if given access to such items. Medications were labeled, as required, and stored in locked areas. No pools or large bodies of water exist on the premises, however, the Assisted living area courtyards have two (2) water fountains. Per Executive Director Danenhauer, residents who are at risk to be near the fountains do not reside in the Assisted Living community, but just in case, residents are generally not alone when in the courtyard.

Per Executive Director Danenhauer, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers of the Assisted Living areas were serviced within the last 12 months, dated for last week. LPA noted that the fire extinguishers in the Memory Care unit hadn't been serviced yet but still within a year for servicing, and it was discovered the servicing company had skipped over the unit. Maintenance was able to contact the company and schedule a return date to complete the extinguisher servicing.

[Continued on LIC 809-C]

NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026

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 TORREY PINES	FACILITY NUMBER: 374604784
	VISIT DATE: 04/28/2026

NARRATIVE

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[Continued from LIC 809-C]

First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility and LPA noted copies of licensing and Ombudsman contact posters were present on each floor. LPA observed resident's engaged in a variety of group and individual activities throughout the facility. LPA also observed staff tending to residents timely and with respect.

LPA interviewed two (2) staff and two (1) client, and interviews did not reveal any additional licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents, however as LPA reviewed staff records, LPA noted that one staff member did not have a health screening and TB test on file, and another had a health screening but no TB test. One Type B deficiency was issued for the missing health screening/TB test for the two (2) staff. Confidential records were stored in locked areas. Maintenance/Disaster records were complete and well organized. Last staff emergency drill was conducted on 4/18/26 for the topic of mattress fire.

Two (2) deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Danenhauer to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Arian Golbakhsh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/01/2026 09:29 AM - It Cannot Be Edited

Created By: Arian Golbakhsh On 04/28/2026 at 03:23 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: BAYSHIRE TORREY PINES	FACILITY NUMBER: 374604784
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in ensuring hot water taps accessible to clients were maintained within the required temperature range, which poses an immediate health and safety risk to all persons in care.
	POC Due Date: 05/07/2026
	Plan of Correction
1 2 3 4	Maintenance staff immediately adjusted the water heater to bring water temperature down and LPA verified it was now in an appropriate range. Licensee will submit a daily log of water temperatures taken in multiple areas of the facility and submit to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:

	Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/01/2026 09:29 AM - It Cannot Be Edited

Created By: Arian Golbakhsh On 04/28/2026 at 03:23 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: BAYSHIRE TORREY PINES	FACILITY NUMBER: 374604784
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file file review and interview, the licensee did not comply with the section cited above in ensuring all staff had a completed health screening and TB test completed and on file, which poses a potential health and safety risk to all persons in care.
	POC Due Date: 05/12/2026
	Plan of Correction
1 2 3 4	Licensee will submit copies of a completed health screening and TB tests for the two staff that did not have the documents on file. Licensee will submit these items to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:

	Arian Golbakhsh
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026

LIC809 (FAS) - (06/04)

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