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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604407
Report Date: 11/06/2024
Date Signed: 11/07/2024 03:20:58 PM

Document Has Been Signed on 11/07/2024 03:20 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 CARLSBADFACILITY NUMBER:
374604407
ADMINISTRATOR/
DIRECTOR:
CHAD COLEMANFACILITY TYPE:
741
ADDRESS:3140 EL CAMINO REALTELEPHONE:
(760) 720-9898
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY: 125CENSUS: 117DATE:
11/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Executive Director Thomas Ozz Daynes and Care Coordinator Ariana VenturaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Care Coordinator Ariana Ventura. Executive Director Thomas Ozz Daynes arrived shortly after.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 10/02/2024). According to the LIC624: on 09/26/2024, Resident #1 (R1) fell and suffered a fracture. [See LIC 811 Confidential Names List for a description of R1.] R1 was sent to the Emergency Room on 09/27/24, then transferred back to Bayshire Carlsbad Skilled Nursing Facility.

During today’s visit, LPA performed a facility tour / welfare check, collected records, and interviewed R1 and the Care Coordinator. LPA did not observe and health and safety concerns. No deficiencies were cited during today's visit.

An exit interview was conducted with Ariana, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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