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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600093
Report Date: 08/08/2025
Date Signed: 08/08/2025 10:46:28 AM

Document Has Been Signed on 08/08/2025 10:46 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: 63DATE:
08/08/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Consultant HoneyLet UrreaTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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On 08/08/25 The Department conducted a subsequent case management visit in response to the Special Incident Report submitted to CCLD on 10/22/24 regarding an incident occurring on 10/20/24.The Department met with Consultant HoneyLet Urrea as the purpose of the visit was explained.

The investigation consisted of the following: On 10/02/24, The Department conducted an unannounced health and safety check to follow up on an incident that occurred on 10/20/24. On 10/02/24 The Department conducted a facility tour, and obtained copies of the following: Staff and client rosters, and the following for client #1 (C1): medication Administration Record from August 1, 2024 - October 27,2024, physician's Reports dated 02/28/23 and 09/23/24, Appraisal/needs and service plan dated 03/01/23, and unusual Incident/Injury Reports dated 09/10/24, 09/13/24, and 10/20/24, (30) day eviction notice dated 10/12/23. On 10/30/24 The Department conducted interviews with staff #1-2 (S1-S2), and Clients #1-3 (C1-C3).

The investigation revealed the following: On 10/22/24, the department received an incident report which stated a client in care was found by staff lying on the floor unresponsive. On 10/30/24 The Department conducted interviews with S1-S2 regarding the incident which occurred on 10/20/24. Per staff interviewed, staff is aware that there is an ongoing drug problem in the area surrounding the facility, however 2 of 2 staff interview deny that staff members are providing drugs to clients in care, and stated staff cannot control what the clients hide and bring into the facility. On 10/30/24 The Department conducted interviews with C1 regarding the incident which occurred on 10/20/24, C1 confirmed the incident occurred and reported obtaining narcotics from a friend who does not live at the facility. On 10/30/24 The Department conducted interviews with C2-C3 regarding the incident which occurred on 10/20/24, C2-C3 reported they have not observed any client using drugs at the facility.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Lizeth Villegas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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