Bayshire Torrey Pines

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced Case Management visit to follow up on a resident death reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Assistant Resident Services Director Agnes Tuazon and was later joined by Executive Director Jeremy Danenhauer. Community Care Licensing received an Incident Report on 09/02/26 in which it was reported that a Resident (Identified as R1) had passed away on 08/28/26 at the hospital after having an unwitnessed fall in the assisted living portion of the facility. During today's visit, LPA conducted file review and interviews, and provided consultation with Executive Director. The facility is currently awaiting the death certificate once cause of death is officially determined and will forward to the Department once received. At this time, LPA observed no immediate health and/or safety concerns and no deficiencies were cited during today's visit. An exit interview was conducted with Executive Director Jeremy Danenhauer to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 3, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Resident Services Director Lizzie Dela Fuente, to discuss the purpose of the visit. Today's visit is in response to the self reported fall of Resident 1, who suffered a shoulder fracture. LPA conducted a wellness check at the facility and interviewed staff and residents. The investigation revealed that R1 experienced an episode of confusion while being assisted with changing clothes. R1 fell to the floor after securely being positioned on their bed with the walker in front of them. The caregiver walked away upon R1's request to obtain a new jacket, due to the jacket R1 was wearing not having been completely dry from being laundered. R1 was interviewed during the visit and confirmed that they were sitting on their bed with their walker in front of them, and that the caregiver walked to the nearby closet to get a new jacket. The information provided by R1 was inconsistent from records and staff interviews, as R1 stated that they attempted to get up and walk without informing the caregiver. R1 also confirmed understanding that they required caregiver assistance before attempting to walk, and that the caregiver was not close enough to help them when they stood up. R1 declined to provide additional details of clarification regarding statements made that did not seem plausible. Records review corroborated staff statements, showing that staff met the expectation of the care plan during assistance. The facility has now upgraded R1's care plan due to a change in behavior while being changed. No health or safety issues were identified. No deficiencies were cited or observed on this date. An exit interview was conducted with Resident Services Director Lizzie Dela Fuente, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22). Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jun 26, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Plan of Correction (POC) visit regarding a deficiency that was cited on 4/28/26. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Jeremy Danenhauer, and Resident Services Director Lizzie Dela Fuente. On 4/28/26 LPA cited a deficiency for two staff members not having complete health screenings and/or TB tests in their file. The POC due date was set for 5/12/26. Licensee did submit items to LPA via email 5/11/26, however LPA could not verify the attachments in the email due to them being encrypted and requiring software to be downloaded for access. LPA emailed back informing the facility that the items were encrypted and needed to be resent in an accessible format. Licensee emailed LPA the items again on 5/14/26 and 5/20/26, both still encrypted. LPA received an email earlier this morning 5/21/26 with the attachments in an accessible format and LPA was able to clear POC. As the Licensee failed to correct the deficiency and notify LPA by the due date, LPA conducted a POC visit to verify correction and to assess a Civil Penalty Violation for Failure to Correct. A Civil Penalty of $100.00 a day has been assessed from 5/13/26 to 5/21/26 for a total of $900.00. An exit interview was conducted with Executive Director Danenhauer to whom a copy of this report, the POC Clearance letter, the LIC 421FC, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 21, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced, required Annual Inspection. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to concierge CJ Isidro, who allowed LPA entry. LPA then met with Executive Director Jeremy Danenhauer and Assistant Resident Services Director Agnes Tuazon. Note, LPA did step out for lunch from 12:30-1:30pm. The facility's license shows a maximum capacity of one-hundred-and-twenty-five (125) non-ambulatory residents, thirty-nine (39) of which may be bedridden. Per the fire clearance, all bedrooms are approved for bedridden occupancy. Additionally, the facility is approved for a hospice waiver for twenty-five (25) and delayed egress in the Memory Care unit. During today’s inspection there were one-hundred-and-four (104) residents in care, with thirteen (13) currently on hospice. LPA and Executive Director Danenhauer toured the interior and exterior of the facility and inspected common areas and a sampling of occupied and unoccupied resident rooms. Director of Mental Health Care David Kraft joined for the tour of the Memory Care unit. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. [Continued on LIC 809-C] [Continued from LIC 809] LPA tested hot water temperatures at taps accessible to clients. A bathroom sink in a resident's unit on the 3rd floor read at 124.9F and another 3rd floor unit tested at 124.3F. LPA additionally tested a sink on the first floor which read at 122F. Maintenance staff went to adjust the water heater and LPA tested the water again and third floor read at 108.7F. One Type A deficiency was issued for the hot water being above the approved range of 105F to 120F. The facility does maintain daily water temperature logs and in the week leading up to today, recorded temperatures routinely ranged from 114-116F. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were stored in the main kitchen which is occupied by staff during the day (kitchen locked at night). The kitchen maintained a system to track resident modified diets and allergies. No toxic chemicals or poisons were accessible to clients at risk if given access to such items. Medications were labeled, as required, and stored in locked areas. No pools or large bodies of water exist on the premises, however, the Assisted living area courtyards have two (2) water fountains. Per Executive Director Danenhauer, residents who are at risk to be near the fountains do not reside in the Assisted Living community, but just in case, residents are generally not alone when in the courtyard. Per Executive Director Danenhauer, no firearms or ammunition are kept at the facility. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers of the Assisted Living areas were serviced within the last 12 months, dated for last week. LPA noted that the fire extinguishers in the Memory Care unit hadn't been serviced yet but still within a year for servicing, and it was discovered the servicing company had skipped over the unit. Maintenance was able to contact the company and schedule a return date to complete the extinguisher servicing. [Continued on LIC 809-C] [Continued from LIC 809-C] First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility and LPA noted copies of licensing and Ombudsman contact posters were present on each floor. LPA observed resident's engaged in a variety of group and individual activities throughout the facility. LPA also observed staff tending to residents timely and with respect. LPA interviewed two (2) staff and two (1) client, and interviews did not reveal any additional licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents, however as LPA reviewed staff records, LPA noted that one staff member did not have a health screening and TB test on file, and another had a health screening but no TB test. One Type B deficiency was issued for the missing health screening/TB test for the two (2) staff. Confidential records were stored in locked areas. Maintenance/Disaster records were complete and well organized. Last staff emergency drill was conducted on 4/18/26 for the topic of mattress fire. Two (2) deficiencies were cited during the inspection. An exit interview was conducted with Executive Director Danenhauer to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Apr 28, 2026

Allegation investigated: Staff Neglect resulted in injury Staff did not meet the resident's care needs Staff did not allow visitation

Licensing Program Analyst (LPA) Ramin Hashemi conducted an unannounced visit to open and deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Lizzie Mistica, Resident Services Director (RSD). During the visit LPA collected facility records, conducted a tour of the facility, and interviewed residents and staff. On 01/27/26 it was alleged "Staff Neglect resulted in injury." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "staff neglect resulted in injury," it was alleged that staff's treatment of Resident 1 (R1) created wounds near R1's groin as a result of neglect or insufficient care. (Continued on LIC9099C, Page 2) Unsubstantiated (Continued from LIC9099, Page 1) Staff interviews revealed: Facility staff unanimously have not heard of neglect occurring within the facility nor has care that has been provided antithetical to the well-being of a resident; specifically R1. Staff 1 (S1) stated that facility doctors make rounds to all residents in the skilled nursing facility (SNF) multiple times a week and adjust care plans to reflect all resident's current needs. Staff 2 (S2) stated that R1's family helps to ensure that communication and advocation for R1 is met and that the staff and R1's family work together to provide R1 reliable care. Staff 4 (S4) confirmed there were no open or closed wounds that have occurred to R1 while they have been under the care of the SNF. Outside source interviews revealed: Outside sources unanimously agreed that the care R1 is receiving is satisfactory. Outside Source 1 (OS1) will typically visit R1 on a daily basis and observes the facility staff caring for R1 in a satisfactory manner. Outside source 2 (OS2) stated they have not witnessed any neglect resulting in injury and are satisfied with the care that R1 is receiving. This corroborates staff interviews. Records Review revealed: R1's care plan dated 05/18/25 states that R1 has a rash service plan which staff will elevate based on observations. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. On 01/27/26 it was alleged "staff did not meet the resident's care needs." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "staff did not meet the resident's care needs," it was alleged that staff are not adjusting care needs of the resident in a timely or safe manner. Staff interviews revealed: Facility staff unanimously agreed that the care that R1 has been provided has evolved to meet their needs as treatment has progressed. S4 stated that while R1 was receiving treatment in the SNF for an infection, R1 developed a rash near the perinatal area due to excessive diarrhea which can commonly occur as a result of antibiotic treatment. S1, S3, and S4 all stated separately that care staff responded quickly and efficiently to treat R1. (Continued on LIC9099C, Page 3) (Continued from LIC9099C, Page 2) Outside source interviews revealed: OS1 and OS2 advocate for R1 if they feel R1 needs more care from the facility. OS1 stated that with the recent rash, facility staff responded quickly with: treatment, visits from medical staff, and medication that has met the needs of R1's care plan. OS1 has stated they have no concerns for the facilities timeliness or approach to treating R1. OS2 stated that the rash that has occurred from treatment is common for R1 and the facility staff are quick to address R1's needs when they arise. Outside source interviews corroborate staff interviews. Records review revealed: R1's Physician's report dated 05/18/25 identified R1 with chronic heart failure and mild cognitive impairment. A SNF care note dated 03/31/2025 stated that R1 has been identified with Crohn's disease. R1's care plan dated 05/18/25 includes skin checks when performing ADL services and a dedicated rash service plan. Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. On 01/27/26 it was alleged "staff did not allow visitation." The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Regarding the allegation, "staff did not allow visitation," it was alleged that staff refuse a special visitor to visit R1 while they stay in Assisted Living (AL) or the Skilled Nursing Facility (SNF). Staff interviews revealed: Staff demonstrated knowledge of visitation rights and resident rights. S1 stated they were aware of the legal situation involving a special visitor of R1. According to S1, S2, and S3, the special visitor of R1 has been denied visitation to R1 through a judge and court order. S1 and S2 stated they have talked to R1's family lawyers, to the court, and to the facility's legal team to ensure that R1's visitation rights are upheld. Facility staff have had to remind the special visitor for R1 of the obligations they must follow in order to visit R1, as a result of the court order. Outside source interviews revealed: Outside sources have confirmed that R1's visitation rights have been followed based on the legal restrictions in place. OS1 stated there have been times when the special visitor has not followed the legal provisions of the restraining order when it came to visiting R1 in the past. This corroborates staff interviews. (Continued on LIC9099C, Page 4) (Continued from LIC9099C, Page 3) Records review revealed: R1's special visitor did not appear at the facility through the time frame the restraining order was active and began visiting again later with a court ordered supervisor. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with RSD Lizzie Mistica, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 08-AS-20260127110332

Allegation investigated: Staff did not administer medication as prescribed Staff did not follow resident's care plan Staff did not follow resident's modified diet

Licensing Program Analyst (LPA) Hannah Rodgers conducted a virtual visit, via video conference, to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Jeremy Danenhauer. On May 8, 2025, it was alleged that staff did not administer medication as prescribed, staff did not follow resident’s care plan, and staff did not follow resident’s modified diet. It was alleged that Resident #1(R1) was no longer receiving their diuretic medication as prescribed, and that staff were not applying an ointment to treat a rash R1 had. It was also alleged that staff were not frequently checking on R1 during their meals as stated in their care plan, and R1 received fried food which goes against their modified diet. [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 Review of R1’s medical assessment records dated May 8, 2025, revealed that R1 required assistance with All Activities of Daily Living (ADLs) except for feeding themself and were non-ambulatory. Also, according to R1’s medical assessment they required a modified diet of mechanical soft and no added salt. Review of R1’s medications list revealed that R1’s diuretic medication was discontinued by a physician. Also, internal and external interviews did not reveal that R1 was not receiving their rash ointment as prescribed. Review of R1’s care plan dated May 18, 2025, revealed that R1 required frequent safety checks and these checks would occur every two hours or as needed and R1 required escorts to and from the dining room. Interviews corroborated that R1 did receive safety checks and was escorted to and from the dining room. Interviews did not reveal that R1 received fried foods, nor did it reveal that R1’s modified diet was not followed. Due to R1’s baseline memory loss they were unable to be used as a reliable historian to aid in this investigation. Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that that staff did not administer medication as prescribed, staff did not follow resident’s care plan, and staff did not follow resident’s modified diet. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegations 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 Executive Director Danenhauer, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Sep 15, 2025 · control 08-AS-20250530115513

Allegation investigated: Staff did not meet resident's incontinence care needs Staff did not follow PPE protocol when providing care to resident

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 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.the state’s words, verbatim · CDSS document, Jul 8, 2025 · control 08-AS-20250702110540

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted by, identified themselves to and discussed the purpose of the visit with Executive Director Jeremy Danenhauer and Resident Service Director Lizzie Dela Fuente Mistica. The facility's license shows a maximum capacity of 125 non-ambulatory residents, of which 39 may be bedridden. Hospice waiver for 17. Delayed egress approved for Memory Care Unit. During today’s inspection there were 91 residents in care. LPA with Resident Service Director De La Fuente Mistica toured the interior and exterior of the facility, and inspected a sample of rooms. Pathways were free of obstruction and slip hazards.The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. Per Resident Service Director De La Fuente Mistica, no firearms or ammunition are kept at the facility. Carbon monoxide detectors and emergency lighting were in working order. Fire extinguisher(s) were serviced within the last 12 months. Required licensing postings were observed in visible areas of the facility. LPA reviewed facility records. Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed. No deficiencies were cited during the inspection. An exit interview was conducted with Resident Service Director De La Fuente Mistica to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 25, 2025

Type of visit: Prelicensing

Licensing Program Analyst’s (LPA’s) Carmen Lopez and Ryan Fulton conducted an announced Pre-Licensing with the Component III inspection, and to observe the facility’s physical plant for complaint with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. LPA’s were greeted at the front entrance by the Executive Director Jermey Danenhauer, Assistant Administrator Veronica Merlos, and Lizzie Dela Fuente and was granted entry after identifying themselves and disclosed the purpose of their visit. The facility is undergoing a change of ownership. The fire clearance was approved on 12/20/2023 and reflected that the facility was approved for 125 residents for Residential Care Facility for the Elderly (RCFE) – Continuing Care Retirement Community (CCRC); all 125 of whom may be non-ambulatory, of which 39 may be bedridden. All rooms are approved for bedridden. Delayed egress is approved for memory care unit and waiver is granted for hospice care for 17. As of today's visit, there were 89 residents in care. The submitted facility sketch was consistent with the current layout of the facility. During today’s visit, LPAs accompanied by Executive Director Jermey Danenhauer, and Assistant Administrator Veronica Merlos, conducted an overall inspection of the internal and external areas of the facility. There are eight number of bathrooms for residents to use. The facility has all the required furnishings, linens and personal hygiene items. Bathrooms are equipped with grab bars and non-skid mats or stickers. The facility was clean, sanitary, and in good repair. Resident bedrooms allowed for easy passage with no obstruction and contained the required furnishings. Toilets, sinks, and showers were in working order. Each window had a screen which was in good condition. The facility’s ambient internal temperature was compliant at 74 degrees F. Hot water temperature at taps accessible to residents were also compliant: 1st floor bathroom sink was 119.2, second first floor bathroom sink was 118.2, second floor spa bathroom sink was 117.2, second floor bathroom sink was 117.5 assisted living 3rd level 113 degrees bathroom 2 118.8 and bathroom 3 was 118.1 there were six resident bedrooms that measured hot water that are in compliance with regulation. All outdoor and indoor pathways were free from obstruction and slip hazards. Fire extinguishers were serviced within the last 12 months and affixed with current tags. Smoke and carbon monoxide detectors, emergency lighting, and facility telephone were present and operational. There are 21 fire extinguishers that are in compliance with regulations. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has no pools or bodies of water that were observed on the facility premises. Per the Executive Director Jeremy Danenhauer, no firearms or ammunition are or will be stored on the facility premise. All toxic substances/poisons, chemicals were stored in an inaccessible area which is inaccessible to residents. Fireplaces, and/or open-faced heaters were inaccessible to residents. The facility has locked areas for storage of sharp objects. The facility kitchen was stocked with appropriate cooking items, knives locked in a secure cabinet which is inaccessible to residents. A seven (7) day non-perishable and two (2) day perishable food supply was present. Medications were secured in a locked cabinet which is inaccessible to residents. A first aid kit and manual were present and located in each of the med rooms and the front entrance. Resident and staff files were also in a locked cabinet. Required licensing postings were observed in visible areas of the facility. LPAs discussed continuing operation requirements, record keeping, reporting requirements and physical plant compliance with the applicant. The items reviewed were complaint with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. The Pre-Licensing and Component III was completed during today’s visit. The applicant was advised that the facility is ready for licensure pending management final review and approval. An exit interview was conducted with applicant, Jermey Danenhauer, to whom a copy of this report along with the licensee Appeal Rights (LIC 9058 01/16) were provided at the conclusion of the visit. The signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Mar 25, 2024

Type of visit: Office

Facility Type: RCFE-CCRC Capacity: 125 Census (if any clients in care): Unknown COMP II Participants: Scott Kirby Interview Method: Telephone interview On March 08, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Mar 8, 2024