<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604407
Report Date: 04/15/2025
Date Signed: 04/15/2025 01:52:15 PM

Substantiated


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
04/02/2025 and conducted by Evaluator Hannah Rodgers
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20250402162550
FACILITY NAME:BAYSHIRE CARLSBADFACILITY NUMBER:
374604407
ADMINISTRATOR:DAYNES, THOMASFACILITY TYPE:
741
ADDRESS:3140 EL CAMINO REALTELEPHONE:
(760) 720-9898
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:125CENSUS: 108DATE:
04/15/2025
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Resident Services Director Pamela TalamantesTIME COMPLETED:
02:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Resident Services Director Pamela Talamantes.

On April 9, 2025, it was alleged that the staff mismanaged resident’s medication. The Department’s investigation consisted of an unannounced facility visit, records review, and staff, resident, and outside source interviews. According to the allegation received, Resident #1 (R1) was mistakenly administered another resident’s medications, to which R1 ingested. It was alleged that a staff member provided R1 with a different resident’s medication resulting in slight change of blood pressure.

[Continued on LIC9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
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 3
Control Number 08-AS-20250402162550
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 CARLSBAD
FACILITY NUMBER: 374604407
VISIT DATE: 04/15/2025
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
26
27
28
29
30
31
32
Review of facility records revealed that facility staff had self-reported this medication error for R1 to the department on April 2, 2024. The records reviewed stated that on April 1, 2025, R1 was administered another resident’s medication mistakenly during a routine medication pass. Review of R1’s medical assessment dated October 24, 2024, revealed that R1 is able to communicate their needs and unable to administer and store their own prescription and PRN medications. Review of R1’s medication log revealed that R1 was not prescribed the two medications they were administered and ingested on April 1, 2025. Interviews with staff, residents, and outside sources all corroborated that R1 has been administered another resident’s medication. R1 did not have any adverse reactions besides a slight decrease in blood pressure but returned to their baseline blood pressure the following day.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of evidence exists to support the allegation. One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Resident Services Director , to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20250402162550
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 CARLSBAD
FACILITY NUMBER: 374604407
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2025
Section Cited
CCR
877645(a)(4)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:
1
2
3
4
5
6
7
Licensee conducted an in-service training 4/01/2025 and 4/02/2025 as a result of the medication error. Licensee provided proof of the training with sign-in sheet and training topic. The deficiency was cleared during LPA's visit.
8
9
10
11
12
13
14
Based on interview and record review, the licensee did not comply with the section cited above as one (1) out of one hundred nine (109) residents received the incorrect medication, which posed a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3