191600093-11-12-2021-11-AS-EMAZ-C9WPFJ-20211221101647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191600093
Report Date: 10/20/2021
Date Signed: 11/12/2021 01:27:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/18/2021 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20211018130925

FACILITY NAME:	BAY BREEZE CARE		FACILITY NUMBER:	191600093
ADMINISTRATOR:	DIMATULAC, RODOLFO		FACILITY TYPE:	735
ADDRESS:	1653- 55 SANTA FE AVE		TELEPHONE:	(562) 432-8033
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90813
CAPACITY:	76	CENSUS: 68	DATE:	10/20/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	RODOLFO DIMATULAC		TIME COMPLETED:	03:47 PM

ALLEGATION(S):

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Facility staff threatened resident with object.

INVESTIGATION FINDINGS:

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On 10/20/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility. LPA met with Administrator Rodolfo Dimatulac and explained the purpose of today's visit is to gather information and deliver finding for the allegation mentioned above.

The investigation consisted of the following: LPA inquired questions relevant to the nature of the complaint. An interview with the administrator and (4) staff and (8) residents. LPA reviewed (S1) personnel and In-Service Training records. A review of incident reports, client/staff rosters and other pertinent documents associated with this complaint. A tour of the entire facility was conducted.

Evaluation Report continues on LIC 9099-C
Amendment: This report serves as an amendment to clarify finding on LIC9099-C. It does not supersedes the complaint investigation findings reflected on report created 10/2021.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20211018130925

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: BAY BREEZE CARE	FACILITY NUMBER: 191600093
	VISIT DATE: 10/20/2021

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Facility staff threatened resident with object.
The Department conducted interviews with staff #1-S#5 (S1-S5) and clients #1-#8 (C1-C8) from this facility. A review of incident reports and (S1’s) personnel records, In-Service Training, and other pertinent documents and found there is no evidence to support the allegation mentioned above.

Details indicated that staff #1 (S1) had threatened a resident with an object. The complainant stated through observation (S1) was engaged in a verbal altercation with a resident. The complainant claims that (S1) was not swinging the baseball bat at the resident at the time she witness this incident. The complainant did not have names, dates, times, or witnesses when the incident occur.

An interview with (S1) claims this allegation is inaccurate. (S1) denies being involved in any verbal altercation with a client or that he had threatened a client with a baseball bat. (S1) states he recalls a recent incident when a former client had accessed inside the facility by trespassing. (S1) reports there was no verbal altercation, and that the former client had a history of being violent with staff or clients when he resided at this facility. (S1) claims that the former client did not have any reason for a social visit and was asked to leave, due to COVID visitation restrictions. (S1) reported no one was hurt during the verbal exchange and that he did not use any threatening object. Upon interviews with staff #2-#5 (S2-S5) all described that this accusation is untrue and that it would be out of character for (S1) to behave in this manner. Furthermore, the staff all verified that mandatory In-Service Diversity Training are conducted. The clients revealed that they are all fond of the staff and that they are treated with the utmost respect. (C1-C8) find the general atmosphere in this facility to be peaceful and not chaotic. In addition, (C1-C8) reported they have not observed any staff with any threatening objects used to intimidate any fellow clients living at this facility. Based on the information gathered, interviews, record reviews, and observation, the Department did not find sufficient evidence to support the allegation mentioned above.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Rodolfo Dimatulac, and a hard copy was provided via email.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

LIC9099 (FAS) - (06/04)

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