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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600093
Report Date: 02/05/2025
Date Signed: 02/05/2025 11:08:38 AM

Document Has Been Signed on 02/05/2025 11:08 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: 59DATE:
02/05/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:31 AM
MET WITH:Jemimah Mejia TIME VISIT/
INSPECTION COMPLETED:
11:03 AM
NARRATIVE
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On February 05, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced Case Management visit at this facility. Administrator Jemimah Mejia greeted LPA. LPA Dabuet explained to Mejia that the purpose of the visit was associated with the incident on January 23, 2025, for Client #1 (C1’s) discharge from the facility due to hospitalization.

An Unusual Incident Report on January 23, 2025, about Client #1 (C1) discharge from Bay Breeze Care due to the hospitalization on November 26, 2024, resulted in a change in condition in which (C1) required a higher level of care that the facility could not provide. LPA Zina Brown followed up with Mejia by telephone on January 24, 2025, which revealed the facility did not comply with California Department of Social Services Community Care Licensing (CDSS/CCL) Title 22 Regulations 85068.5 Eviction Procedures. The facility failed to provide a modified needs and service plan, outlined in the notice to quit the reasons for the eviction, with specific facts, notify or mail a copy of the notice to leave to the client’s authorized representative, and a written report of eviction notice sent to the licensing agency within five days of the eviction.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed, and citation issued (ref. LIC 809-D).

An exit interview was conducted, and a copy of the Evaluation Report and Appeal Rights were provided to the Administrator (Jemimah Mejia).
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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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Document Has Been Signed on 02/05/2025 11:08 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 02/05/2025 at 10:28 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: 02/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/12/2025
Section Cited
CCR
85068.5(a)(4)(c-e)

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85068.5 Eviction Procedures (a) The licensee shall be permitted to evict a client by serving the client with a 30-day written notice...(c) The licensee shall set forth in the notice to quit the reasons for the eviction...(d) The licensee shall, upon completion of the procedures... notify or mail a copy of the notice to quit to the client's authorized representative...(e) A written report of any eviction processed in accordance... sent to the licensing agency within five days of the eviction.
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Licensee will review Title 22 85068.5 Eviction Procedures. Licensee shall also send a written statement to CCL to the attention of LPA Dabuet. Proof of correction is due by 02/12/25. The Licensee will reissue a 30-day Eviction Notice and submit to CCL within five days of the eviction.
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This requirement is not met as evidenced by:
Licensee failed to comply with Title 22 85068.5 Eviction Procedures and issued an illegal Eviction Notice to (C1). This violation poses a potential health or safety for 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.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
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