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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006421
Report Date: 09/17/2025
Date Signed: 09/17/2025 04:36:03 PM

Document Has Been Signed on 09/17/2025 04:36 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BAYSHIRE YORBA LINDAFACILITY NUMBER:
306006421
ADMINISTRATOR/
DIRECTOR:		COLEMAN, CHADFACILITY TYPE:
741
ADDRESS:17803 IMPERIAL HWYTELEPHONE:
(714) 777-9666
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 114CENSUS: 97DATE:
09/17/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 PM
MET WITH:Executive Director- Austin morrisTIME VISIT/
INSPECTION COMPLETED:
11:30 PM
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On September 17, 2025, at 8:45 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced Case Management Visit to follow-up on a death report received from the facility. LPA Kim was greeted by Executive Director (ED) Austin Morris and LPA Kim explained the purpose of the visit. ED Morris could not stay for the visit and stated Resident Service Director Mirian Im could sign on behalf of the facility.

During today’s visit, LPA conducted a health and safety check, and there were no imminent health/safety concerns observed. Facility is maintained at a comfortable temperature for the residents in care. LPA obtained Staff Roster, Resident Roster, and R1’s records which includes the Physician’s Report, Emergency Information, Appraisal and Needs/Service Plan, and other pertinent documents. LPA interviewed two staff and one witness.

Based on record review, the Incident report received by the Orange County Regional Office on September 12, 2025, R1 was sent to the hospital on September 10, 2025, due to shortness of breath and noticeable confusion during a Home Health Nurse visit. On an incident report dated September 16, 2025, dated on September 13, 2025, around 2:00 AM, R1 passed away. The incident report dated September 16, 2025, and the hospital discharge summary dated September 12, 2025, both stated R1 returned to the facility on September 12, 2025, diagnosed with Chronic Obstructive pulmonary disease (COPD). The hospital discharge report on page 6 stated COPD is a lung disease, where the lungs get damaged making it hard to get air in and out of the lungs. The damage cannot be changed. R1’s physicians report dated July 15, 2025, diagnosed R1 with COPD. There is no coroner’s report but a card with the coroner case number and death report number was provided to the facility.
Evaluation Report Continues on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BAYSHIRE YORBA LINDA
FACILITY NUMBER: 306006421
VISIT DATE: 09/17/2025
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Based on interviews conducted, one witness and two staff denied this to be a questionable death. W1 stated R1 passed away due to natural causes. There is no foul play suspected from the facility. S2 stated on September 10, 2025, a home health nurse noticed that R1 had a collapsed lung. From the recommendation of the nurse, the facility sent R1 to the hospital to be treated.

Based on record review and interviews conducted, this incident is not a questionable death.

No deficiencies were observed during this visit.

An exit interview was conducted, and a copy of this report was provided to the Resident Service Director Mirian Im.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Edward Kim
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
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