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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600093
Report Date: 11/21/2024
Date Signed: 11/21/2024 12:34:09 PM

Document Has Been Signed on 11/21/2024 12:34 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: 60DATE:
11/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:57 AM
MET WITH:Kristen Angeles, Facility CoordinatorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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 November 21, 2024 at 8:57am Licensing Program Analyst (LPA) Zina Brown conducted an unannounced health and safety check to follow up on a incident that occurred on November 17, 2024. During today visit we met with Kristen Angeles (Facility Coordinator) and explained the purpose of the visit.

During today's visit, LPA conducted interviews with staff and clients. LPA also reviewed and collected the following:
  • Roster of Facility Clients/Staff
  • LIC 500: Personnel Report
  • LIC 601: Identification and Emergency Information (Clients #1 - Client #2)
  • LIC 602: Physician's Report for Community Care Facilities (Clients #1 - Client #2)
  • LIC 625: Appraisal/Needs and Services Plan (Clients #1 - Client #2)
  • LIC 624: Unusual Incident/Injury Report
  • Medication list for (Client #1 & Client #2)
  • Staff Training (facility will scan and email staff training to LPA Zina Brown)
  • Reviewed video surveillance footage of the incident that occurred on 11/17/2024 (requested video to be submitted to community care licensing)
Due to insufficient information available at this time a further investigation is needed.

A exit interview was conducted with Kristen Angeles (Facility Coordinator), and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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