191600093-4-20-2022-11-AS-JHAD-CEB29A-20220510171137

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191600093
Report Date: 04/20/2022
Date Signed: 04/20/2022 12:43:46 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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/19/2022 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20220419084932

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: 65	DATE:	04/20/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	ADMINISTRATOR RODOLFO DIMATULAC		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident was physically assaulted sustaining injury caused by another resident while in care.

INVESTIGATION FINDINGS:

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On 04/20/2022 around 9 am Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA Calderon met with Administrator Rodolfo Dimatulac and the purpose of the visit was explained.

The Investigation consisted of the following: On 04/20/2022 LPA Calderon interviewed Administrator Rodolfo Dimatulac and conducted a tour of the physical plant. LPA Calderon obtained copies of Staff and Resident rosters, Needs and Service Plan, Physicians Report for R1 and R2, incident report, copy of police report on 04/20/2022 LPA Calderon interviewed staff S2-S3 regarding complaint and on 04/20/2022 LPA Calderon attempted to interviewed R1-R2 for complaint.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

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-20220419084932

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
MONTEREY PARK, CA 91754

FACILITY NAME: BAY BREEZE CARE	FACILITY NUMBER: 191600093
	VISIT DATE: 04/20/2022

NARRATIVE

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Allegation: Resident was physically assaulted sustaining injury caused by another resident while in care
It is alleged that resident was physically assaulted sustaining injury caused by another resident while in care. On 04/20/2022 LPA Calderon interviewed S1 who stated he was informed that R1 was attacked by R2 and that R1 was taken to the hospital and R2 was arrested by the police. On 042/20/2022 LPA Calderon interviewed S2-S3 who stated that they were working on 04/18/2022 and noticed that R2 was acting aggressive towards other residents. Staff state that this is the first time R2 was aggressive with other residents. Staff state that R2 deals with schizophrenia and takes medication. Staff state that they spoke to R2 who calmed down. Staff states that R2 walked to the back-parking lot where R1 was smoking. Staff state that they were watching the video monitor and noticed R2 push R1 to the ground and then kick R1 in the head. Staff they ran to the back-parking lot and stopped the assault. Staff states that they called 911 and gave first aid to R1 who had a laceration to the head. Staff state that police arrived and arrested R2 and at the same time R1 was taken to the hospital for evaluation. Staff states that 20 minutes later R2 was returned to the facility as no charges were filed. Staff states that around 11pm R1 was returned to the facility with no serious injuries noted. On 04/20/2022 LPA Calderon reviewed Needs and Service Plan and Physician Report for R1 and R2. Per medical reports both residents have chronic paranoid schizophrenia, difficulty in adjusting socially and maintain personal relationship. On 04/20/2022 LPA Calderon attempted to interview R1 and R2 for complaint. Each resident refused to speak to LPA Calderon and walked away. On 04/20/2022 LPA Calderon called and left message for witness to call regarding the complaint.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

A telephonic exit interview was conducted with Administrator Rodolfo Dimatulac, and a hard copy was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

LIC9099 (FAS) - (06/04)

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