<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600093
Report Date: 10/28/2024
Date Signed: 10/28/2024 12:10:15 PM

Document Has Been Signed on 10/28/2024 12:10 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:BAY BREEZE CAREFACILITY NUMBER:
191600093
ADMINISTRATOR/
DIRECTOR:		MEJIA, JEMIMAHFACILITY TYPE:
735
ADDRESS:1653- 55 SANTA FE AVETELEPHONE:
(562) 432-8033
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY: 76CENSUS: 61DATE:
10/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Jemimah Mejia, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On October 2, 2024 at 9:40am Licensing Program Analyst (LPA) Zina Brown conducted an unannounced health and safety check to follow up on a incident that occurred on October 20, 2024

During today visit we met with Jemimah Mejia, Administrator and explained the purpose of the visit.

During today's visit, LPA conducted a tour of the facility of the common areas such as shower rooms, women's restroom, men restroom, dining areas, kitchen and activity room.
LPA also reviewed and collect documents such as LIC 500: Personnel Report
  • Roster of Facility Clients/Residents
    Medication Administration Record from August 1, 2024 - October 27,2024 (for resident #1)
  • LIC 602: Physician's Report for Community Care Facilities
  • LIC 603: Preplacement Appraisal Information
  • LIC 624: Unusual Incident/Injury Report

Due to insufficient information available at this time a further investigation is needed.

A exit interview was conducted with Jemimah Mejia, and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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 1