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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600093
Report Date: 10/16/2022
Date Signed: 10/16/2022 12:09:51 PM

Document Has Been Signed on 10/16/2022 12:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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: 62DATE:
10/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Rudolfo Dimatulac TIME COMPLETED:
12:29 PM
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On 10/16/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Rudolfo Dimatulac. LPA explained the purpose of today’s visit. The facility is licensed to serve (76) mentally disordered ambulatory adults ages 18-59 years of age.

The facility is a two-story two structure building located in a commercial neighborhood. It consists of the following: (38) clients’ bedrooms. The building has common men's and women's restroom.with showers. The facility houses an activity room, dining area, kitchen, administrative offices, laundry, and outside patio area.

LPA toured the physical plant with Dimatulac. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #9; #6; #2; #26; #28; #25; #24, and #41. Smoke/carbon monoxide were all tested and were in operable condition. The water temperature ranged from 105.1– 116.4 degrees F. The room temperature ranged from 71--74 degrees F.

LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. Several working landline phones are available on-site. A review of (6) clients’ service files (C1-C6) and (6) staff personnel files (S1-S6) and Medication Administration Records (MAR) were accurate and maintained in order.

Evaluation Report continues on LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/16/2022
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INFECTION CONTROL:
LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of residents' and staff COVID vaccinations were conducted for (C1-C6) and staff (S1-S6). The facility has provided CCLD with an approved Mitigation Plan and has submitted an Infection Control Plan and Monkey Pox Plan for 2022.

No Deficiencies were identified during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Rudolfo Dimatulac.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2022
LIC809 (FAS) - (06/04)
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