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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600093
Report Date: 10/28/2023
Date Signed: 10/28/2023 03:02:42 PM

Document Has Been Signed on 10/28/2023 03:02 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: 63DATE:
10/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Rodolfo DumatulacTIME COMPLETED:
02:56 PM
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On 10/28/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Rodolfo Dimatulac. LPA explained the purpose of today’s visit. The facility is licensed to serve (76) mentally disabled 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 premise. 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: #2; #6; #9; #24; #28; and #41. Smoke/carbon monoxide were all tested and were in operable condition. The water temperature ranged from 105.0 degrees F. The room temperature ranged from 71--74 degrees F.

LPA observed the facility to be clean 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. The facility conducted the last emergency fire/earthquake drills on 10/12/23.

Evaluation Report continues on LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 10/28/2023
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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. Interviews were conducted with (3) clients and (3) staff. The facility is current on CCL annual license fees. The facility has a current administrator's certification for Rodolfo Dimatulac #6031716735 Expiration: 07/09/24. The currently manages client's finances. A Surety Bond was provided and is current.

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 the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.
No Deficiencies were identified during this inspection visit.

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

DATE: 10/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023
LIC809 (FAS) - (06/04)
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