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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191600093
Report Date: 08/19/2024
Date Signed: 08/19/2024 11:32:23 AM

Substantiated


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
08/12/2024 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20240812150230
FACILITY NAME:BAY BREEZE CAREFACILITY NUMBER:
191600093
ADMINISTRATOR:DIMATULAC, RODOLFOFACILITY TYPE:
735
ADDRESS:1653- 55 SANTA FE AVETELEPHONE:
(562) 432-8033
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY:76CENSUS: 63DATE:
08/19/2024
UNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Jemima Mejia-AdministratorTIME COMPLETED:
11:31 AM
ALLEGATION(S):
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Staff does not ensure facility is free of pests.
INVESTIGATION FINDINGS:
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On 8/19/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Jemima Mejia/Administrator. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Client’s interviews (C#1-C#8) and Witness Interview (W#1). LPA obtained and reviewed the following documents: Client’s roster, Personnel roster, a health and safety check of the facility, copies of Commercial Services Agreement with Orkin.


Evaluation Report continues LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 11-AS-20240812150230
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: 08/19/2024
NARRATIVE
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Investigation Revealed the Following:

Allegation: Staff does not ensure facility is free of pests.

The details of the complaint alleged that staff does not ensure facility is free of pests.



During the records review, LPA Iniguez reviewed the facility’s commercial service agreement with Orkin. LPA noticed that services are set only once a month to treat roaches, common ants, rats, and mice. On the other hand, LPA observed that the facility has the option to get services up to four times per month.

During an Interview with the Administrator (A#1), she stated that the facility is not free of pests. There are roaches and other pests, and (A#1) stated that they have seen roaches and other pests at the facility. In addition, (A#1) stated that the facility has a commercial services agreement with Orkin, and they come once a month. Moreover, (A#1) stated that the facility is clean and sanitary for clients in care.

During interviews with clients (C#1-C#8), (7) out of (8) stated that there are pests in the facility, and they have seen roaches in their rooms. Also, they feel safe living here.

During an interview with Witness 1 (W#1), they stated that when they came to retrieve (C#1)’s belongings at the facility, the facility staff gave them to them in plastic bags. Once they opened them at home, they saw dead and live roaches inside the bags.


Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20240812150230
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: 08/19/2024
NARRATIVE
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During this investigation, LPA found sufficient evidence to support the above-mentioned allegation.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D.

An exit interview was conducted, and a copy of the Complaint Report was given to Jemima Mejia /Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20240812150230
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2024
Section Cited
CCR
80087(a)(1)
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80087 Buildings and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
(1) The licensee shall take measures to keep the facility free of flies and other insects.
This requirement was not met as evidence by:
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Licensee will ensure facility is free of pests at all times. As plan of correction, licensee will increase amount of visits from pest company until pests are erradicated. A proof of new contract will be send to LPA via email before POC due date.
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Based on a review of records and interviews, the facility staff did not ensure the facility is free of pests. This poses a potential health and safety risk to all residents in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4