191600093-9-23-2023-11-AS-MVAO-CW3SAP-20230927134240

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191600093
Report Date: 09/23/2023
Date Signed: 09/23/2023 03:02:01 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/22/2022 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20221122094922

FACILITY NAME:	BAY BREEZE CARE		FACILITY NUMBER:	191600093
ADMINISTRATOR:	DIMATULAC, RODOLFO		FACILITY TYPE:	735
ADDRESS:	1653- 55 SANTA FE AVE		TELEPHONE:	(562) 432-8033
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90813
CAPACITY:	76	CENSUS: 69	DATE:	09/23/2023
		UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Rudolfo Dimatulac		TIME COMPLETED:	10:59 AM

ALLEGATION(S):

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Staff are not safeguarding residents’ belongings.
Staff are not preventing resident from being threatened by other resident(s) in care.
Staff are not preventing residents from being verbally abused by other resident(s) in care.

INVESTIGATION FINDINGS:

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On 09/23/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent visit to this facility. LPA was greeted by Administrator Rodolfo Dimatulac. LPA explained the purpose of today's inspection visit is to deliver findings for the allegations mentioned above.

The investigation consisted of the following: LPA obtained copies of the roster for clients and staff. Service records for client #1 (C1) which included: Client Fact Sheet, ALW Assessment, Physicians Report, Appraisal/Needs Service Plan, Resident Assessment, Medications List, Voluntary Termination of Rental Agreement, and other pertinent documents associated with this complaint. Interviews with staff #1-#3 (S1-S3), clients #2-#10 (C2-C10), and witness #1 ((W1). An inspection of the facility on 09/21/23.

(Evaluation Report cotinues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 11-AS-20221122094922

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BAY BREEZE CARE	FACILITY NUMBER: 191600093
	VISIT DATE: 09/23/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff are not safeguarding residents’ belongings.

The details of this complaint alleged staff are not safeguarding client #1 (C1’s) personal property. The complainant reported two clients #2-#3 (C2-C3) at this facility are abusive towards (C1) and are taking or moving items around without (C1’s) knowledge or permission. The Department contacted the complainant who was not available to provide further information regarding this allegation.

According to client #1 (C1's) service records, (C1) was a resident at this facility between 08/27/20 through 04/20/23. Upon admission, (C1’s) property items were listed in the Client/Resident Personal Property and Valuables LIC 621 (dated: 08/27/20) which included: clothing items, identification items, medications, and cash. These same items were listed on (C1’s) Voluntary Termination of Rental Agreement (dated 04/20/23) acknowledged by (C1) with a signature.

On 09/21/23 between 9:45 am – 01:59 pm (9) clients (7) out of (9) clients #2-#8 (C2-C8) claimed they did not have issues or concerns for their property items. (C2-C8) reported no personal property valuables have gone missing or stolen. (C9-C10) had some personal items taken from their rooms but explained they failed to secure locked the doors or left the room briefly unattended. (C2-C3) identified by the complainant, stated not having knowledge of (C1’s) property items being displaced or removed from (C1’s) room. (C4) who was a former roommate of (C1) described (C1) with frequent forgetfulness who accused individuals for disappearance of personal items and a few days later will be recovered. (C2-C10) recognized that it is the clients who is responsibility for safeguarding their items and not the staff.

Interviews conducted with (3) staff members between 2:00 pm -3:30 pm (3) out (3) staff #1-#3 (S1-S3) confirmed not knowing (C1’s) missing personal items. (S2-S3) verified that (C1) did not report any incidents involving (C2-C3). (S1-S3) stated to ensure the safety of all residents the facility has provided only individual keys to residents assigned in their room and a 24/7 monitoring surveillance camera system operated to capture visual evidence of activities that occur within the facility grounds. (S1) reported a resident’s council meeting “In-Service Program” is mandated with all clients to discuss topics of House Rules and Client Care.
(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20221122094922

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BAY BREEZE CARE	FACILITY NUMBER: 191600093
	VISIT DATE: 09/23/2023

NARRATIVE

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There were no interviews with (C1) on 12/02/22 and 09/21/23 during investigation visits. (C1) voluntarily terminated residency effective 04/20/23, without leaving a forwarding address or telephone number. Therefore, based on all the information obtained during the investigation, there is no evidence to corroborate the allegation mentioned above.

Allegation #2: Staff is not preventing the resident from being threatened by other resident(s) in care.
Allegation #3: Staff are not preventing residents from being verbally abused by other resident(s) in care.

The details of this complaint alleged staff are not preventing client #2-#3 (C2-C3) from threatening and verbally abusing client #1 (C1) while in care. The complainant reported (C2-C3) is verbally abusive towards (C1) and has used foul language and threaten (C1). The complainant added that staff #2 and #3 (S2-S3) both were aware of the abuses and had ignored and neglected to act. The Department contacted the complainant who was not available to provide further information regarding these allegations.

On 09/21/23 between 9:45 am – 01:59 pm (9) clients (9) out of (9) clients #2-#8 (C2-C10) claimed they did not have issues or concerns with staff proactive and responsive in ensuring the safety and welfare of clients living at this facility. (C4) a former roommate of (C1) reported that (C1) created many of (C1’s) scenarios through imagination and these events did not have “merit". (C4) reported not to have witness any type of abuse with (C1) while in care at this facility. (C2-C3) denied having any involvement with (C1).

Interviews conducted with (3) staff members between 2:00 pm - 3:30 pm (3) out (3) staff #1-#3 (S1-S3) confirmed not being aware of (C1’s) threats or abuse involving (C2-C3). (S1-S3) reported there were no incidents involving (C1) in the years 2020 through 2022. Incidents started to surface in (02/26/23, 03/28/23, 04/11/23, and 04/17/23) aggressive acts towards staff and self all documented in Unusual Incident Reports LIC 624. (S1-S3) claimed to take immediate action with clients as soon an incident is observed or reported. (S1-S3) claimed any mistreatment of clients is reported immediately to Community Care Licensing, Law Enforcement, Crises Team, and Adult Protective Services. According, to (S1) a resident’s council meeting “In-Service Program” is conducted monthly with all clients, and in line #12 and #13 of the facility’s House Rules guidelines is discussed with clients that zero tolerance for malicious abusive acts is not tolerated.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20221122094922

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BAY BREEZE CARE	FACILITY NUMBER: 191600093
	VISIT DATE: 09/23/2023

NARRATIVE

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Assisted Living Waiver Behavior assessment of (C1) (date: 08/03/20) listed (C1) has difficulty in situations, judgment sometimes is impaired, attitude, habits, and emotional state create frequent interactions problems with others, often agitated, disruptive/or aggressive either physical or verbally. (C1) is currently on (9) prescribed medications, and (7) out of (9) have side effects that can reasonably attributed to psychiatric disorders (e.g., anxiety, depression, and confusion) cited by the (Mayo Clinic).

Interviews were not available with (C1) on 12/02/22 and 09/21/23 during investigation visits. (C1) voluntarily terminated residency effective 04/20/23, without leaving a forwarding address or telephone number. This information was confirmed on 09/21/23 at 12:31 p.m. by (ALW) case manager witness #1 (W1) that no contact information for (C1). Therefore, based on all the information obtained during the investigation, there is no evidence to support the allegations mentioned above.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur as a result, the allegations are unsubstantiated.

A copy of this report and an exit interview were conducted with Rudolfo Dimatulac.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

LIC9099 (FAS) - (06/04)

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