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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191600093
Report Date: 10/17/2024
Date Signed: 10/17/2024 11:57:46 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
10/10/2024 and conducted by Evaluator Zina Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241010120020
FACILITY NAME:BAY BREEZE CAREFACILITY NUMBER:
191600093
ADMINISTRATOR:MEJIA, JEMIMAHFACILITY TYPE:
735
ADDRESS:1653- 55 SANTA FE AVETELEPHONE:
(562) 432-8033
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY:76CENSUS: 61DATE:
10/17/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jemimah Mejia, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Licensee did not ensure the facility telephone on the premises was working.
INVESTIGATION FINDINGS:
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On 10/17/2024 at 9:47am, LPA Zina Brown and LPM Janae Hammond initiated a unannounced complaint investigation for the allegation listed above. During today’s visit, LPA and LPM met with Jemimah Mejia (Administrator) and the purpose of the visit was explained.

The investigation consisted of the following:
On 10/17/2023, LPA and LPM interviewed A1, Staff #1-3 (S1 – S3) and Client #1- #7 (C1 – C7)

LPA, requested copies of the staff roster and resident roster (dated on 10/17/2024)

On 10/17/2024, LPA called facility to ensure phone line is operational.

The investigation revealed the following:
Allegation: Licensee did not ensure the facility telephone on the premises was working.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
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 3
Control Number 11-AS-20241010120020
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: 10/17/2024
NARRATIVE
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On 10/17/2024 at 10am, LPA interview the Administrator (A1), regarding the above allegation.
A1 stated since she started working at the facility as an administrator, the phone have stopped working twice. A1 stated that the first time that the phone were not working occurred in mid-August and then again last week (10/7 – 10/11). A1 stated community care licensing was not notified and that if residents need to use the phone, she will allow the clients to use her personal phone or the med room phone.

On 10/17/2024 between the hours of 10:15am – 10:45am, LPA interview Staff # 1 – Staff #3 regarding the allegation. 2 out of the 3 staff interviews, confirmed the allegation and 1 of the 3 staff interviewed was unaware of the allegation.

On 10/17/2024 between the hours 10:45am – 11:15am interviewed clients #1 - #7, 4 out of the 7 clients confirmed the allegation and 3 out of 7 clients denied being aware of the allegations.

On 10/17/2024 at 10am, LPA confirmed that the facility is working.
Substantiated: Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview conducted with Jemimah Mejia (Administrator) and copy of the report and appeal right were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20241010120020
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: 10/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2024
Section Cited
CCR
80073(a)
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Telephone: All facilities shall have telephone service on the premises.

This requirement was not met by as evidence by:
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Administrator will ensure the facility telephone is operational at all time and will report to licensing on a special incident report by POC due date to LPA.
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based on interviews, the facility telephone was not operational. This poses as a potential personal right risk to clients 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: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3