374604407-5-5-2025-08-AS-APAO-DGGM4Z-20250508091731

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604407
Report Date: 04/28/2025
Date Signed: 05/05/2025 10:50:45 AM

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
07/01/2021 and conducted by Evaluator Becky Kennedy

COMPLAINT CONTROL NUMBER: 08-AS-20210701105133

FACILITY NAME:	BAYSHIRE CARLSBAD		FACILITY NUMBER:	374604407
ADMINISTRATOR:	HIGHTOWER, SASHA		FACILITY TYPE:	741
ADDRESS:	3140 EL CAMINO REAL		TELEPHONE:	(760) 720-9898
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92008
CAPACITY:	125	CENSUS:	DATE:	04/28/2025
		UNANNOUNCED	TIME BEGAN:	01:22 PM
MET WITH:	Pamela Talmantes, Resident Services Director		TIME COMPLETED:	01:53 PM

ALLEGATION(S):

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Insufficient staff to meet residents care needs.
Facility is not kept clean.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Becky Kennedy conducted an unannounced complaint investigation visit to the facility to deliver findings on the above allegations. LPA identified herself and was granted entry to the facility. LPA met with Pamela Talmantes, Resident Services Directof and explaining the reason for the visit.

It was alleged that the facility did not have enough staff to meet the resident’s needs. Specifically, it was alleged that the facility only had one care staff member for the entire facility. Lack of care staff resulted in Resident 1 (R1) being left on the toilet for over an hour two times, on another occasion R1 called for care and no one came and R1 soiled themself.

The Department’s investigation consisted of review of facility records, outside source records, and interviews of facility staff and outside sources.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Icela Estrada
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210701105133

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: 04/28/2025

NARRATIVE

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Through interviews the investigation revealed that in the time frame covered by this complaint, facility staffing was of concern. Information was obtained that there was not any time when only one direct care staff had responsibility for the entire facility. Interviews revealed that the facility had strategies for when staffing is less than standard. The first is having all staff trained and required to supplement direct care staff as needed. An example is that medication staff will provide direct care. The other is to use a staffing agency to supplement regular employees. It was acknowledged that providing care for some residents may have taken longer than when they were fully staffed, but no evidence was revealed to determine that resident care needs went unmet or went unmet for an excessive period of time.

Through interviews and a review of records, the investigation revealed that several of the specifics of the above allegations were regarding second-hand information. The extemporaneous notes from the individual who reportedly would have had the firsthand information did not mention any neglect or lack of care. Interviews did not reveal information that would support those allegations. This allegation is unsubstantiated.

It was further alleged that the facility was not kept clean. Through interviews and observation it was revealed that the facility had stains on the on carpet and on a ceiling tile. Documents revealed that the facility had been licensed for one month when the allegation was made. The licensee had the carpets professionally cleaned two times in that month. The carpets were in place at the time the facility was licensed. The stained carpet, and the ceiling tile were replaced as verified by subsequent observation. Interviews revealed that housekeeping staff clean each room once a week. Minor cleaning, such as for spilled items, is conducted on an as needed basis by floor staff and larger cleanliness needs are reported to maintenance staff for a resolution. Although there were stains on the carpet, the investigation revealed that facility made appropriate efforts to eliminate the stains and replaced the carpet when those efforts were unsuccessful. This allegation is unsubstantiated.

Based on the evidence obtained during the complaint investigation, both allegations above are UNSUBSTANTIATED, meaning there isn’t enough evidence to prove a violation occurred.
An exit interview was conducted with Pamela Talmantes, Resident Services Director; a copy of this report and Licensee's Rights (LIC9058) were provided.

SUPERVISORS NAME: Icela Estrada
LICENSING EVALUATOR NAME: Becky Kennedy
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025

LIC9099 (FAS) - (06/04)

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