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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600093
Report Date: 11/26/2024
Date Signed: 11/26/2024 10:47:08 AM

Document Has Been Signed on 11/26/2024 10:47 AM - 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: 62DATE:
11/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
MET WITH:Kristine Angeles, Facility CoordinatorTIME VISIT/
INSPECTION COMPLETED:
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On 11/26/2024, Licensing Program Analyst, LPA Zina Brown conducted a Case Management visit to follow up on the death reported for Client #1 (C1). LPA was greeted by facility coordinator Kristine Angeles and and assistant administrator Anna Marie Peji. LPA explained the purpose of the visit was to gather information surrounding the death of (C1).

The regional office received a copy of the death report from the facility who reported the death of (C1) on 11/25/2024. The death report stated that (C1) passed away on at Long Beach Memorial Hospital(LBMH) According to the incident report (C1) was admitted on 11/23/2024 for general weakness. Emergency Medical Services were dispatched on 11/23/2024, (C1) was not feeling well. A staff was notified by 911 in regards to (C1) due C1 have a history of calling 911 unfalse pretenses. (EMS) arrived to the facility to transport (C1) to the hospital immediately.

(C1) while under hospital care passed away at the hospital. The facility was notified of (C1's) passing by (C1's) public guardian.

The following documents were requested:
  • ID and Emergency Information (dated: 05/23/2023)
  • Admission Agreement (dated: 05/23/2023)
  • Physician Report for Community Care Facilities LIC 602A (dated: 10/05/2024)
  • Preplacement Appraisal Information LIC 603 (dated: 05/23/2023)
  • Medications (MAR)
  • Incident Report LIC 624 (dated: 4/23/23 - 4/01/24)

An exit interview was conducted with Kristine Angeles(Facility Coordinator) and a hard copy was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE:
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE:
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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