Bayshire Torrey Pines.

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.

(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) 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 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) 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 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.

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.

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.

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: 1 st 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 3 rd 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. 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 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.

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 readiness