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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191600093
Report Date: 09/08/2022
Date Signed: 09/08/2022 02:35:52 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
08/29/2022 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220829085532
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: 65DATE:
09/08/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rodolfo DimatulacTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility is not providing a safe environment for resident in care.
INVESTIGATION FINDINGS:
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On 9/8/22, Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced complaint visit at this facility. LPA conducted risk assessment before entering the building and LPA observed Covid-19 Protocol. LPA met with Administrator Rodolfo Dimatulac and explained the purpose of today's visit was to investigate the above allegation.

The investigation consisted of the following: LPA Brown toured the entire facility with the administrator. LPA obtained staff/clients roster, Residents #C1 and #C2 physicians reports, Mars, Needs & Service, emergency contacts and Staff Members #1-2 training records. Interviews were conducted with Administrator and assistant Administrator, staff members #2-#3 and Clients #1-7.

Investigation revealed the following:
LIC 9099C is on the next page.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
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 2
Control Number 11-AS-20220829085532
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BAY BREEZE CARE
FACILITY NUMBER: 191600093
VISIT DATE: 09/08/2022
NARRATIVE
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Regarding the allegation: Facility is not providing a safe environment for resident in care.

Details of the complaint is that a client is being threaten by roommate and feared for life. Client also stated staff will not help move. On 9/8/22, LPA conducted interview with Administrator and assistant both stated the facilities environment is quiet. Clients may argue with each other but there have not been any threats. Both stated clients may get agitated in the morning before having their medications. Both stated if there are any disagreements they will give verbal warning and written. Both stated activities are also provided to clients such as exercise, crafts and bingo. Interviews conducted with Staff #2-3 stated they haven’t seen or heard any clients threatening each other or any recent altercations. Interview with client #1 stated feels like someone is trying to manipulate and kill them. Interviews with Clients #2-7 stated they feel safe in the facility, clients stated the and have no concerns with how staff treats them. LPA reviewed the needs and service plans of clients #1-2 and both are diagnosis with Schizophrenia. Reviewed medication list and mars. During today’s visit LPA observed clients working on arts & crafts and in the activity room. Based on interviews conducted there is insufficient evidence to support the allegation.

Although the allegation is valid or may have happened there is insufficient evidence to support the alleged violations did or did not occur, therefore the allegation are unsubstantiated.

Exit interview conducted and a copy of the report was provided to Dimatulac.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2