Inspection Reports for Bayshire Yorba Linda
17803 Imperial Hwy., Yorba Linda, CA 92886, United States, CA, 92886
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, including allegations about staffing, hot water availability, and staff qualifications. The most recent report from September 17, 2025, was clean with no deficiencies and confirmed a death was due to natural causes without foul play. Earlier inspections cited some deficiencies, mainly related to maintaining proper hot water temperatures and medication administration errors, as well as a substantiated personal rights violation involving improper restraint and incomplete criminal record clearances for staff in April 2024. These issues were isolated, and the facility showed improvement over time, with no deficiencies found in the latest follow-up visits. No fines, license suspensions, or enforcement actions were listed in the available reports.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 97
Capacity: 114
Deficiencies: 0
Sep 17, 2025
Visit Reason
The visit was an unannounced Case Management follow-up on a death report received from the facility.
Findings
No imminent health or safety concerns were observed during the visit. Based on record review and interviews, the incident was determined not to be a questionable death, and no deficiencies were found.
Complaint Details
The visit was complaint-related to a death report. Interviews with staff and a witness confirmed the death was due to natural causes with no foul play suspected. The incident was not substantiated as questionable.
Report Facts
Facility capacity: 114
Census: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Kim | Licensing Program Analyst | Conducted the inspection and authored the report |
| Austin Morris | Executive Director | Met with the Licensing Program Analyst at the start of the visit |
| Mirian Im | Resident Service Director | Signed on behalf of the facility and received a copy of the report |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 114
Deficiencies: 0
Aug 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility does not have hot water.
Findings
The investigation included observations, interviews, and record reviews which found water temperatures within acceptable ranges and mixed staff and resident reports. There was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged that half of the building was experiencing hot water issues, with intermittent water shutoffs and lack of resolution by a plumber. Interviews showed some staff and one witness confirmed the allegation, while others denied it. Water temperature logs from July 6 to August 13, 2025, showed temperatures never below 105°F or above 120°F. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Water temperature measurements: 115
Water temperature measurements: 113.5
Water temperature measurements: 117.3
Water temperature measurements: 118
Water temperature measurements: 116.6
Water temperature measurements: 112.6
Water temperature measurements: 114.4
Water temperature measurements: 113.7
Water temperature measurements: 116.2
Water temperature measurements: 115.7
Water temperature measurements: 114.8
Water temperature measurements: 114.4
Water temperature measurements: 109.7
Water temperature log range: 105
Water temperature log range: 120
Staff interviewed: 12
Residents interviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Kim | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Austin Morris | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Lourdes Montoya | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Plan of Correction
Census: 94
Capacity: 114
Deficiencies: 0
Aug 15, 2025
Visit Reason
The visit was a case management Plan of Correction (POC) visit to clear a deficiency observed during a case management visit on July 10, 2025, and was conducted in conjunction with the investigation of complaint 22-AS-20250703163459.
Findings
During the visit, water temperature readings in several resident bathrooms were observed and documented, with temperatures ranging from 113.7 to 117.3 degrees Fahrenheit. A 24-hour water temperature log completed on July 11, 2025, was provided, and a POC letter documenting corrections was given to the facility representative.
Complaint Details
Investigation was conducted in conjunction with complaint 22-AS-20250703163459; no substantiation status explicitly stated.
Report Facts
Water temperature reading: 117.3
Water temperature reading: 116.6
Water temperature reading: 113.7
Capacity: 114
Census: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Kim | Licensing Program Analyst | Conducted the case management POC visit |
| Austin Morris | Executive Director | Facility representative met during inspection and provided documentation |
Inspection Report
Census: 90
Capacity: 114
Deficiencies: 1
Jul 10, 2025
Visit Reason
A case management visit was conducted to document a deficiency observed during the investigation of complaint 22-AS-20250703163459, unrelated to the allegations investigated.
Findings
The facility did not maintain hot water temperatures between 105 and 120 degrees Fahrenheit in resident rooms 103, 112, and 135, with temperatures measured above 120 degrees, posing an immediate health or safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility did not maintain hot water temperature between 105 degrees F and 120 degrees F for resident rooms 103, 112, and 135. | Type A |
Report Facts
Water temperature: 125
Water temperature: 121.4
Deficiency Plan of Correction due date: Jul 11, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Kim | Licensing Program Analyst | Conducted the case management visit and documented the deficiency |
| Austin Morris | Executive Director | Met with during the inspection and received the report and appeal rights |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 114
Deficiencies: 0
May 5, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2025-02-11 regarding staffing sufficiency in the memory care unit, safeguarding of resident property, and adequacy of personal care supplies.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Observations, interviews, and record reviews indicated that staffing levels met residents' needs, resident property was appropriately safeguarded, and adequate personal care supplies were available or provided as per admission agreements.
Complaint Details
The complaint included allegations that the facility did not have sufficient staff in the memory care unit, failed to safeguard resident's property, and failed to ensure adequate personal care supplies. The investigation concluded the allegations were unsubstantiated due to lack of sufficient evidence.
Report Facts
Memory care residents: 22
Staff providing direct care in memory care unit: 4
Facility capacity: 114
Facility census: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Kim | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Austin Morris | Executive Director | Facility representative met during the investigation and exit interview |
Inspection Report
Annual Inspection
Census: 84
Capacity: 114
Deficiencies: 2
May 5, 2025
Visit Reason
The inspection was an unannounced required 1-Year annual visit conducted to assess compliance with licensing requirements using the CARE Inspection Tool.
Findings
The facility was found to be generally well-maintained, sanitary, and appropriately furnished with adequate supplies and emergency preparedness. However, deficiencies were cited related to medication administration not following physician's directions for four residents and one staff member lacking a valid TB test.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Four out of nine residents' medications were not given according to physician's directions, posing a potential health, safety, and/or personal rights risk. | Type B |
| One out of eight staff did not have a valid TB test in their records, posing a potential health, safety, and/or personal rights risk. | Type B |
Report Facts
Resident files audited: 9
Staff files audited: 8
Resident interviews conducted: 6
Staff interviews conducted: 4
Medication deficiencies: 4
Staff with missing TB test: 1
Plan of Correction Due Date: May 19, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Austin Morris | Executive Director | Participated in the inspection tour and exit interview |
| Miriam Im | Resident Service Director | Met with Licensing Program Analysts during the inspection tour |
| Edward Kim | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Follow-Up
Census: 82
Capacity: 114
Deficiencies: 0
Apr 2, 2025
Visit Reason
An unannounced Case Management Visit was conducted to follow-up on incident reports received from the facility.
Findings
During the visit, a health and safety check was conducted with no imminent health or safety concerns observed. No deficiencies were cited during this visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edward Kim | Licensing Program Analyst | Conducted the unannounced Case Management Visit and interviews. |
| Austin Morris | Executive Director | Greeted the Licensing Program Analyst and was present during the visit. |
| Chad Coleman | Administrator | Named as facility administrator. |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 114
Deficiencies: 0
May 29, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that the Administrator was not present in the facility and not qualified to be an Administrator.
Findings
The investigation found that the allegations were unfounded. Staff provided evidence that the current Administrator is qualified and holds a valid Administrator's certificate, and the Administrator's presence in the facility varies but is consistent with scheduling fluctuations.
Complaint Details
The complaint was filed on 2024-05-23 alleging the Administrator was not present and not qualified. The investigation determined the allegations to be unfounded.
Report Facts
Capacity: 114
Census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the complaint investigation visit |
| Chad Coleman | Administrator | Named as the current Administrator with a valid certificate |
| Luz Adams | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 114
Deficiencies: 0
May 7, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that unqualified staff are allowed to work at the facility.
Findings
The investigation found the allegation to be unfounded after interviews and document review, confirming that staff were qualified and the complaint was false.
Complaint Details
The complaint alleged that unqualified staff were allowed to work at the facility. Two staff members interviewed denied the allegation. Documentation including a valid Administrator's Certificate was provided for the staff in question. The allegation was deemed unfounded.
Report Facts
Complaint control number: 22
Complaint control number suffix: 20240502113510
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jeff Stewart | Executive Director | Met with during the investigation |
| Chad Coleman | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 114
Deficiencies: 2
Apr 16, 2024
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report sent to the Regional Office dated April 13, 2024, regarding a personal rights violation.
Findings
Staff interviews and document review confirmed a personal rights violation involving a resident being restrained improperly, and deficiencies related to criminal record clearance for two staff members were cited.
Complaint Details
The visit was complaint-related, following an incident report. A personal rights violation was substantiated based on staff interviews and document review.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Personal Rights of Residents violated by staff restraining a resident by grabbing their arms and confining them to a wheelchair, posing an immediate health and safety risk. | Type A |
| Criminal Record Clearance requirement not met as two staff members were not properly cleared prior to working in the facility, posing an immediate health and safety risk. | Type A |
Report Facts
Capacity: 114
Census: 79
Deficiencies cited: 2
Plan of Correction Due Date: Apr 17, 2024
Inspection Report
Original Licensing
Census: 82
Capacity: 114
Deficiencies: 0
Mar 26, 2024
Visit Reason
The visit was an announced pre-licensing inspection conducted to evaluate the facility for initial licensing and certification.
Findings
The facility was toured and found to have appropriate safety features including fire extinguishers, smoke and carbon monoxide detectors, locked medication rooms, and emergency call systems. The facility was stocked with necessary supplies and was deemed ready to be licensed.
Report Facts
Bedrooms in Assisted Living: 90
Residents in Assisted Living: 60
Bedrooms in Memory Care: 23
Residents in Memory Care: 22
Hot water temperature range (degrees F): 107.1-119
Fire clearance capacity: 114
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Mendivil | Licensing Program Analyst | Conducted the pre-licensing visit and inspection |
| Marie Stern | Director of Operations | Met with Licensing Program Analyst during the visit and toured the facility |
| Hrag Bekerian | Administrator | Met with Licensing Program Analyst during the visit and toured the facility |
Inspection Report
Original Licensing
Capacity: 114
Deficiencies: 0
Mar 19, 2024
Visit Reason
The visit was conducted as a telephone interview for the Change of Ownership (CHOW) application process, verifying the applicant/administrator's understanding of community care facility licensing laws and readiness for licensing.
Findings
The applicant and administrator confirmed their understanding of licensing laws, facility operation, admission policies, staffing requirements, restrictive health conditions, emergency preparedness, complaints reporting, and pre-licensing readiness. Identification was verified and required documentation was obtained.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chad Coleman | Administrator | Applicant/administrator participating in licensing interview and verification |
| Julia Kim | Licensing Program Manager | Named as Licensing Program Manager overseeing the evaluation |
| Nicole Rouse | Licensing Program Analyst | Named as Licensing Program Analyst conducting the evaluation |
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