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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604407
Report Date: 07/17/2025
Date Signed: 07/21/2025 03:39:58 PM

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
04/27/2022 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20220427154859
FACILITY NAME:BAYSHIRE CARLSBADFACILITY NUMBER:
374604407
ADMINISTRATOR:HIGHTOWER, SASHAFACILITY TYPE:
741
ADDRESS:3140 EL CAMINO REALTELEPHONE:
(760) 720-9898
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:125CENSUS: DATE:
07/17/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Pamela Talamantes, Resident Service DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained injuries while in care.
Resident's not allowed to go to their rooms during the day.
Staff did not respond to resident's call light in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Amy Rodgers met with Resident Services Director(RSD), Pamela Talamantes, to deliver findings on the above-mentioned allegation. LPA identified herself and disclosed the purpose of her visit, and conducted the meeting via phone call.

On April 27, 2022, Community Care Licensing (CCL) received a complaint alleging that the Resident #1(R1) sustained injuries while in care, residents are left in a large room all day and cannot go to their rooms, and licensee staff did not respond to the call light in a timely manner. [See LIC811 Confidential Name List to identify select person identifiers used in this report]. The Department’s investigation consisted of an unannounced facility visit, records review, and staff, resident, and outside source interviews.

(Continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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 2
Control Number 08-AS-20220427154859
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: 07/17/2025
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
(Continued from 9099)


Resident #1 (R1) was a resident of the facility’s memory care unit from 3/30/22 to 4/3/22 following discharge from skilled nursing. During R1's stay, they were non-ambulatory and required one to two person assistance with activities of daily living, including transfers, toileting, and mobility due to an unsteady gait when rising from their wheelchair. R1 was incontinent of bowel and bladder and demonstrated cognitive impairment, responding with limited verbal ability.

Regarding the allegation, the resident sustained injuries while in care, and staff did not respond to the resident's call light in a timely manner. Records show the facility performed a skin assessment on 4/1/2022, and on 4/2/2022, R1 was assisted to the bathroom by a family member when another fall occurred during transfer. Interviews with staff and the family provided conflicting information regarding the timing and staff response.. Additionally, outside source interviews did not support the claim that staff neglected the residents’ needs. Review of the facility’s call light policy indicates proactive monitoring is encouraged, and there is evidence the team remains alert and responsive.

Regarding the allegation, residents are not allowed to go to their rooms during the day. Outside source interviews and staff interviews do not support this allegation. Interviews with staff reveal that residents in the memory care typically leave their personal room door open. Interviews with staff reveal that the facility's policy is to promote resident engagement through group activities designed to encourage socialization and support active participation in the community. These activities generally take place in a large common area within the memory care unit.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed UNSUBSTANTIATED.



An exit interview was conducted with Resident Services Director(RSD), Pamela Talamantes . A copy of this report was provided and their signature on this report confirms receipt.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2