191600093-8-9-2024-11-AS-JHAD-D8825J-20240816170538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191600093
Report Date: 08/09/2024
Date Signed: 08/09/2024 09:10:45 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2024 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240808094025

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: 63	DATE:	08/09/2024
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Rudolfo Dimatulac & Jemimah Mejia		TIME COMPLETED:	04:39 PM

ALLEGATION(S):

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Client sustained unexplained bruising while in care.

INVESTIGATION FINDINGS:

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On 08/09/24, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to this facility and was greeted by Administrator (A#1: Rodolfo Dimatulac). LPA explained the purpose for today’s visit is to gather information pertaining to the above-mentioned allegation.

The investigation consisted of the following: A tour of the physical plant, interviews, and collection of records. (LPA) Dabuet reviewed the following documents: Facility Roster Clients/Residents (dated: 08/09/24); Personnel Report LIC 500 (dated: 08/06/24); Client #1 (C#1's) ID and Emergency Information LIC 601(dated: 12/20/22); Physicians Report LIC 602 (dated: 01/29/24) Preplacement Appraisal Information LIC 603 (dated: 12/20/22 & 01/29/24); Medication Administration Record (dated: 08/01/24 – 08/31/24); Unusual Incident Report LIC 624 (dated: 08/05/24); Los Angeles Community Hospital After Care Instructions (dated: 12/20/22); and LACH Patient Information (dated: 12/20/22). Interviews with clients #1-#7 (C#1-C#7), administrators (A#1 A#3), and witnesss (W#1- W#3).

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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-20240808094025

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BAY BREEZE CARE	FACILITY NUMBER: 191600093
	VISIT DATE: 08/09/2024

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

The details of the complaint reported on 08/03/24 that client #1 (C#1) had sustained unexplained bruising while in care at this facility. (C#1) was found with suspicious bruises in the perineal area of the body. The report did not provide any further details.

Investigation revealed client #1 (C#1) was admitted at Bay Breeze Care on 12/20/22 according to Identification and Emergency Information (dated: 12/20/22). (C1) voluntarily terminated residency from Bay Breeze Care on 08/05/24. Physician’s Report (dated: 01/29/24) and Preplacement Appraisal Information (date: 12/18/22 & 01/29/24) identified (C1) can self-care and is independent and requires assistance only with dispensing medications.

On 08/03/24 at 08:30 am, (C#1) was hospitalized at College Medical Center due to Dysarthria and Essential tremors. Medical information revealed (C#1) observed bruises in the perineal area of (C#1’s) body.

On 08/09/24 between 09:15 am - 09:45 am, the Department interviewed (3) out of (3) administrators #1-#3 (A#1-A#3) who reported having no knowledge of (C#1) sustaining bodily bruises. (A#1-A#3) described (C#1) as independent and with minimal social interactions with other residents or staff. (A1) claimed that (C#1) is ambulatory and requires no assistive devices. (A#1-A#3) stated that (C#1) was not on any required medical restraint while in care. (A#1-A#3) stated that (C#1) had no accidents, falls, or physical altercations while in care. (A#1-A#3) reported that (C#1’s) out of the community involvement consist of performing domestic errands.

On 08/09/24 between 10:16 am -11:16 am, the Department interviewed (6) out of (6) clients #2-#7 (C#2-C#7) who claimed to have never experienced or know clients that have sustained bodily injuries/bruises while in care. (C#2) who shared a room with (C#1) claimed that (C1) never mentioned any pain from injuries or sustained bruises. (C#2) did mention that (C1) did have some skin rashes that were under control on medically prescribed ointments. (C#2-C#7) were complimentary of the staff and stated the staff is responsive to the client’s medical attention when it is required.

On 08/09/24 between 11:17 am -12:40 pm, the Department interviewed (3) out of (3) witnesses #1-#3 (W#1-W#3) who had observed or were aware of (C#1’s) bodily bruises. Licensed vocational nurse (LVN), (W#3) indicated that (C1) had a rash for several months, and it was being treated with a prescribed Hydrocortisone.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240808094025

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BAY BREEZE CARE	FACILITY NUMBER: 191600093
	VISIT DATE: 08/09/2024

NARRATIVE

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The rash was on various parts of (C1’s) body and some skin rashes can lead to bruises. According to (W3), (C#1) was taken for a medical lab test on 08/01/24, and (C#1) did not mention any discomfort related to bodily bruises.

On 08/09/24 between 02:06 pm - 02:16 pm, the Department interviewed client #1 (C#1) by telephone now recovering at Sunset Villa Post Acute. (C#1) denied having sustained bruises on any part of the body. (C#1) was not on any medical restraint devices. (C#1) denied being involved in physical altercations, falls, or accidents. (C#1) does recall being treated for skin rashes. (C#1) denied experiencing any discomfort as a result of bruises, cuts, wounds, or lacerations.(C#1) claimed the staff responded appropriately to (C#1's) medical needs.

As a result of the Department reviewing (C#1’s) Physician Report LIC 602A (dated: 01/29/24), Preplacement Appraisal Information LIC 623 (dated: 12/20/22 & 01/29/24); Unusual Incident Report LIC 624 (dated: 08/05/24); Los Angeles Community Hospital After Care Instructions (dated: 12/202/22); and LACH Patient Information (dated: 12/202/22), (C#1) experienced skin irritations. Medication Administration Record (dated: 08/01/24 – 08/31/24), revealed (C#1) is on (20) routine medications. Fourteen (14) out of twenty (20) prescribed medications have side effects related to skin problems, unusual bleeding, and bruises according to the National Institute of Health (ref: NIH). Based on the gathered information, there is no evidence to support the allegation mentioned above.

Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned in this complaint. 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 is conducted with Jemimah Mejia, and a copy of the report is provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC9099 (FAS) - (06/04)

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