191600093-1-29-2024-11-AS-EMAZ-D22UVM-20240201145522

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191600093
Report Date: 01/29/2024
Date Signed: 01/29/2024 12:58:51 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2024 and conducted by Evaluator Alfonso Iniguez

COMPLAINT CONTROL NUMBER: 11-AS-20240122142452

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: 57	DATE:	01/29/2024
		UNANNOUNCED	TIME BEGAN:	09:19 AM
MET WITH:	Rodolfo Dimatulac-Licensee		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff are not providing adequate food service to residents

INVESTIGATION FINDINGS:

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On 1/29/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Rodolfo Dimatulac/Administrator. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Client’s interviews (C#1-C#5) and Staff Interviews (S#1-S#5). LPA obtained and reviewed the following documents: Client’s roster, Personnel roster, (C#1-C#5) Identification and Emergency Information, (C#1-C#5) Admissions agreements, (C#1-C#5) Physicians Report for Residential Care Facilities for the Elderly, (C#1-C#5) Needs and Services Plan, (C#1-C#5) Medication Administration Record (MAR) for the month of January 2024, a physical tour of facility’s kitchen and food pantry, copies of facility menu from November and December-2023 and January and February-2024 and copies of Dietician’s report from November and December 2023 and January 2024, and copy of cook’s State Food Safety-Food Manager Certification and copy of California Food Handlers Course Certificate.

Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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 3

Control Number 11-AS-20240122142452

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/29/2024

NARRATIVE

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Investigation Revealed the Following:

Allegation: Staff are not providing adequate food service to residents.

The details of the complaint alleged that facility staff are not providing adequate food service to clients in care.

During the records review, LPA Iniguez observed copies of the facility menu from November, December-2023, and January-February 2024. On the menus, various meals are offered to clients in care. In addition, the menus are created by the facility’s registered dietitian (RD). (RD) follows the guidelines from USDA DGA 2015. In addition, LPA reviewed (RD)’s registration on file. Also, LPA reviewed (RD)’s Kitchen Sanitation and Safety Reports from November, December 2023, and January 2024; these reports are an evaluation (RD) conducts to oversee the kitchen’s food production, equipment, and dining room. On the other hand, LPA reviewed (S#1)’s State Food Safety-Food Manager Certification completed on 9/29/2023 with an expiration date of 9/29/2028 and California Food Handlers Course Certificate completed on 5/21/2023 with an expiration date of 5/21/2026. Moreover, LPA reviewed (C#1-C#5)’s Admission Agreement, stating that the facility will provide basic general services such as (3) nutritious meals daily and between meals nourishment or snacks.

During the physical tour of the facility's kitchen and food pantry, LPA observed plenty of perishable and non-perishable food available and a 7-day food supply for emergencies. In addition, LPA observed the facility menu display in the common area next to the dining room; the whiteboard displays the menus for the day: breakfast, lunch, and dinner. In addition, LPA observed the facility's kitchen, food pantry, and dining area to be clean and sanitary during the visit.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20240122142452

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/29/2024

NARRATIVE

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During an Interview with the Administrator (A#1), he stated that currently, at the facility, there are (57) clients in total. In addition, (A#1) stated that the facility has a full-time registered dietitian in charge of the facility's weekly menu and food ordering. Also, (A#1) stated that the facility serves 3 meals daily plus snacks to clients and provides well-balanced and nutritious meals to clients in care.

During interviews with clients (C#1-C#5), (5) out of (5) stated that they get 3 meals per day plus snacks, and the facility menu is displayed on a whiteboard by the dining room. In addition, (5) out of (5) stated that the facility serves well-balanced and nutritious meals to them. Also, (5) out of (5) stated that they feel safe living here.

During interviews with staff (S#1-S#5), (5) out (5) stated that the facility has a menu and facility serves the clients 3 meals per day plus snacks. In addition, (5) out of (5) staff stated that the facility serves well-balanced and nutritious meals to clients in care.

During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) is found to be UNSUBSTANTIATED.

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

California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted, and a copy of the Complaint Report was given to Rodolfo Dimatulac /Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC9099 (FAS) - (06/04)

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