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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604784
Report Date: 07/08/2025
Date Signed: 07/08/2025 02:31:24 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
07/02/2025 and conducted by Evaluator Hannah Rodgers
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20250702110540
FACILITY NAME:BAYSHIRE TORREY PINESFACILITY NUMBER:
374604784
ADMINISTRATOR:JEREMY DANENHAUERFACILITY TYPE:
741
ADDRESS:13101 HARTFIELD AVETELEPHONE:
(858) 259-2222
CITY:SAN DIEGOSTATE: CAZIP CODE:
92130
CAPACITY:125CENSUS: 100DATE:
07/08/2025
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Resident Services Director Lizzie De La Fuente MisticaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not meet resident's incontinence care needs
Staff did not follow PPE protocol when providing care to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced visit to initiate and deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Resident Services Director Lizzie De La Fuente Mistica.

On July 2, 2025, it was alleged that staff did not meet resident’s incontinence care needs and staff did not follow Personal Protective Equipment (PPE) protocol when providing care to resident. It was alleged that Resident #1 (R1) is being left in their soiled incontinence briefs for extended periods of time, and that Staff #1 (S1) used the same gloves and cloth to provide incontinence care to R1 after it was used to clean the floor. [See LIC811 Confidential Name List for identification of 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 LIC9099-C)

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Hannah Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
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-20250702110540
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 TORREY PINES
FACILITY NUMBER: 374604784
VISIT DATE: 07/08/2025
NARRATIVE
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Per interviews, R1 was receiving incontinence assistance from S1. Interviews did not reveal that S1 used the same gloves and cloth to provide incontinence care to R1 after cleaning the floor. Internal and external interviews did not reveal that R1 is left in soiled incontinence briefs for extended periods of time.

Review of R1’s physician’s report dated May 8, 2025, revealed that R1 could feed themselves but required assistance with all other activities of daily living, has bowel and bladder impairment and wears incontinence briefs. Review of R1’s resident assessment dated May 18, 2025, revealed R1 requires routine incontinence checks. Interviews verified this need for R1.

Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that staff did not meet resident’s incontinence care needs and staff did not follow Personal Protective Equipment (PPE) protocol when providing care to resident. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Resident Services Director Lizzie De La Fuente Mistica, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

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

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2