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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 10:57:22 AM

Document Has Been Signed on 08/08/2025 10:57 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:
08:54 AM
MET WITH:Consultant HoneyLet UrreaTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
NARRATIVE
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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 about an incident occurring on 11/17/24. The department met with Consultant HoneyLet Urrea as the purpose of the visit was explained.

The investigation consisted of the following: On 11/21/24 The Department conducted an unannounced health and safety check to follow up on an incident that occurred on 11/17/24. On 11/21/24 The Department obtained copies of the following: Staff and client rosters, and the following for client #1-2 (C1-C2): face sheets, physicians report, appraisal, needs and service plan, unusual incident report, medication list, and staff training. The Department obtained a copy of Bay Breeze surveillance footage of incident occurred on 11/17/24. The Department received a copy of the Long Beach Police Department (LBPD) investigation report, that includes interviews conducted on 11/21/24 with Clients #1,3,4 (C1, C3, C4).

The investigation revealed the following: On 11/17/24 interviews were conducted with C1, C3, and C4, 3 of 3 clients interviewed confirmed the allegation as they were present during the incident on 11/21/24. The Department was unable to interview C2 as C2 was incarcerated. On 01/28/25 and 02/05/25 interviews were conducted with staff #1- 4(S1-S4). 2 of the 4 staff interviewed reported being on shift on the day of the incident, 1 of 4 staff interviewed confirmed the allegation and reported yelling for help rather than intervening due to fear and assisting was not in the staffs job description. 1 of the 4 staff interviewed confirmed the allegation and confirmed they did not intervene, but verbally instructed clients to stop and proceeded to contact law enforcement. 2 of 4 staff interviewed reported they were not scheduled to work on the day of the incident 11/17/24. The Department received a copy of Bay Breeze video surveillance footage of incident occurred on 11/17/24, the video revealed an incident occurred between C1 and C2, in which C2 attacked C1 repeatedly. Review of the video surveillance footage also revealed there were no staff were present during

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 191600093
VISIT DATE: 08/08/2025
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the incident, nor did staff intervene during the incident to de-escalate clients. The video surveillance shows when LBPD arrived at the facility to address the incident and arrest C2. The Department conducted a review of LBPD report, and it is noted that C1 sustained a laceration on left cheek, (2) missing teeth, and had blood coming from face and mouth out caused by C2.

Based on the departments observations, interviews, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. An immediate $500 dollar civil penalty was assessed.

At this an Enhanced Civil Penalty assessment determination is pending by the department for Serious Bodily Injury in accordance with the Health & Safety Code.

Exit interview conducted, appeal rights explained, 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
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/08/2025 10:57 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 08/08/2025 at 10:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BAY BREEZE CARE
FACILITY NUMBER: 191600093

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2025
Section Cited
CCR
80072(a)(2)

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80072Personal Rights
Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:To be accorded safe, healthful and comfortable accommodation, furnishings and equipment to meet
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Licensee shall review the section cited, and submit a plan to CCLD detailing how the facility will ensure clients persoanl rights are not violated, and how all clients in care will be accorded safe, healthful, and comfortable accommodations. To be sent by POC due date.
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his/her needs. Based on records review, and interviews the licensee did not comply with the section cited above as licensee did not ensure there are safety measures in place for all clients in care which poses a health and safety risk to clients in care.
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Type B
08/22/2025
Section Cited
HSC80065(a)

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80065Personnel Requirements-Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. Based on records review, and interviews on the day of the incident
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Facility shall employee staff to meet clients’ needs. License shall submit a plan to the department by POC due date to comply.
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there were no direct support staff/caregivers on duty. There were not enough staff on duty to assist with de-escalating the incident. This poses a health & safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Lizeth Villegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/08/2025 10:57 AM - It Cannot Be Edited


Created By: Lizeth Villegas On 08/08/2025 at 10:36 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BAY BREEZE CARE
FACILITY NUMBER: 191600093

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2025
Section Cited
CCR
85064(a)

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85064 Administrator Qualifications and Duties
The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation. This requirement is not met as evidenced by:
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Licensee/Administrator shall review the section cited and submit documentation indicating the understandment of the section cited. Licensee/Administrator to review re-assessment process for clients in care, licnesee/Administrator to submit plan to CCLD by POC due date, plan shall
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Based on interviews and records review the administrator failed to properly manage the facility when Administrator was aware of C2 behaviors had increased. This poses a health & safety issue risk to clients in care.
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document what steps the facility will be taking to ensure that the clients are receiving the proper care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Lizeth Villegas
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2025


LIC809 (FAS) - (06/04)
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