191600093-5-24-2024-11-AS-JHAD-D5PQAS-20240528120021

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191600093
Report Date: 05/24/2024
Date Signed: 05/24/2024 04:15:26 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
09/07/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230907162238

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: 60	DATE:	05/24/2024
		UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Rodolfo Dimatulac		TIME COMPLETED:	10:31 AM

ALLEGATION(S):

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Questionable death.

INVESTIGATION FINDINGS:

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On 05/24/24, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to this facility and was greeted by Licensee and Administrator (A#1: Rodolfo Dimatulac). LPA explained the purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegation.

A 24-hour visit was conducted by Licensing Program Analyst (LPA) Jose Calderon on 09/08/23 for health & safety purposes and to ensure the wellbeing of clients in care. The investigation consisted of the following: a tour of the physical plant, interviews, and collection of records. (LPA) Calderon reviewed the following documents: Facility Roster Client/Residents; Personnel Report Staff Roster (dated: 08/25/23); Client #1 (C#1)’s Face Sheet (dated: 06/08/23); Physicians Report LIC 602 (dated: 05/30/23) Appraisal/Needs and Service Plan LIC 625 (dated: 06/08/23); Individual Service Plan (dated: 05/30/23), Refusal of Treatment Form (dated: 05/17/23) Medication Administration Record (dated: 07/01/23 – 007/31/23);
(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

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 4

Control Number 11-AS-20230907162238

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: 05/24/2024

NARRATIVE

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Warning Notice (dated: 08/18/23); Facility Client Interview Questionnaires (dated: 06/08/23); Facility Internal Progress Notes (dated: 08/16/23 08/18/23); and Facility Internal Photographs of (C#1) (dated: 07/1/23,07/11/23,07/19/23 and 08/12/23).

The complaint was referred to the California Department of Social Services Investigations Branch and was assigned to Investigator (Heidy Bandana) which included a review of (C#1)’s Client #1 (C#1)’s Face Sheet; Physicians Report LIC 602 (dated: 05/30/23) Appraisal/Needs and Service Plan LIC 625 (dated: 06/08/23); Individual Service Plan (dated: 05/30/23), Refusal of Treatment Form (dated: 0/17/23) Medication Administration Record (dated: 07/01/23 – 007/31/23); Warning Notice (dated: 08/18/23); Facility Client Interview Questionnaires; Facility Internal Progress Notes (dated: 08/1623 08/18/23), and Facility Internal Photographs of (C#1) (dated: 07/1/2307/11/23,07/19/23,and 08/12/23); Los Angeles County Fire Department Emergency Medical Services (EMS) Report #2023243209000 (dated:8/25/23) Death Report LIC 624A (dated: 08/25/23); Coroner Investigator Business Card; Chest X-Ray Results; Admissions Agreement (dated: 06/08/23); ID and Emergency Information LIC 01 (dated: 06/08/223); Bay Breeze House Rules; Functional Capability Assessment LIC 9172 (dated: 06/08/23); Preplacement Appraisal Information LIC 603 (dated: 06/08/23) New Patient Registration Form; Conservatorship Court Letters; Los Angeles County Department of Medical Examiner Coroner Report Case #202-11259 (dated: 10/30/23);Long Beach Police Department Incident Report; (dated: 08/31/3); interviews with administrator #1-#2(A#1-#2); staff #1-#3 (S#1-S#3); and clients #2-#4 (C#2-#C3).

INVESTIGATION REVEALED THE FOLLOWING:

The details of the complaint reported on 08/25/23 that client #1 (C#1) was found unresponsive. (C#1) was found in (C#1)’s room at around 9:45 am, with paramedics performing cardiopulmonary resuscitation (CPR), and later was determined deceased.

On 09/12/23, (CDSS) Investigation Branch Investigator Heidy Bendana reviewed the Los Angeles County Fire Department Emergency Medical Services (EMS) 911 call and Incident Report. The date of the report listed the incident as 08/25/23 at 09:46 am. (EMS) arrived at the scene and found (C#1) with a chief complaint of full arrest. (C#1) was described as pulseless and apneic while a staff was performing (CPR) on (C#1). (C#1) had no obvious signs of trauma but was found with asystole rhythm. After 20 minutes of (CPR) with no change in rhythm, (C#1) was determined deceased. The time of death was listed at 10:12 am.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20230907162238

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: 05/24/2024

NARRATIVE

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On 11/16/23, (CDSS) Investigation Branch Investigator Heidy Bendana reviewed the Long Beach Police Department incident report. The report indicated that housekeeper staff #1 (S#1) on 08/25/23 at 08:40 am, checked (C#1)’s room for cleaning. (S#1) observed (C#1) and client #2 (C#2) sleeping in bed together. (S#1) observed both were breathing, while she cleaned the room and left. (C#3) found (C#1) at approximately 9:50 am when (C#3) walked into the room and observed (C#1) lying flat on the bed, head down. (C#3) picked up (C#1) who was foaming at the mouth and called for help. Facility staff came to help (C#3) and 911 was dispatched. (C#2) reported that (C#1) did drugs on 08/25/24 at approximately 02:00 am. (C#2) claimed drugs were obtained outside of the facility. Evidence of empty syringe had partially smoked hand rolled cigarettes were found in (C#2) shared room. The items believe to have illicit substance (C#1 and C#2) had consumed. According to the Long Beach Police Report, the nature of the death is a possible overdose of narcotics. The Los Angeles Coroner was called to report an overdose death, case number 2320-1159.

On 09/27/203, between 01:09 pm – 02:21 pm, (CDSS) Investigation Branch Investigator Heidy Bendana interviewed administrator #1-#2 (A#1- A#2) and staff #1-#3 (S#1-S#3). (A#1-A#2) confirmed working on 08/25/23, and both were informed by (S#1) that (C#1) was ill or unconscious. (A#1-A#2) immediately dispatched for emergency assistance and claimed to have no awareness of (C#1) having a history with illegal drugs. (A#1) expressed there is a drug policy and workshops to prevent drug use for clients in care. Furthermore, any use of illicit drugs is subject to warnings or possible eviction from the facility. (S1) recalled the incident on 08/25/23 and that (S1)’s statements made with the Long Beach Police Department and Los Angeles County Fire Department (EMS) were consistent. (S#1) reported she concluded cleaning (C#1)’s room between 8:35 am – 8:40 am and noticed both (C#1) and (C#2) lying in bed together breathing. (S#1) claimed at approximately 09:30 am, (S#1) heard screams from (C#3) and ran over to (C#1)’s room and observed (C#1) foaming from the mouth and nose. (S#1) went into the office and informed the staff of the situation. (S#1-S#3) validated to have never witnessed (C#1) or other clients do drugs and has not seen drug paraphernalia with clients in care.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20230907162238

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: 05/24/2024

NARRATIVE

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On 09/27/23, between 01:01 pm – 02:41 pm, (CDSS) Investigation Branch Investigator Heidy Bendana interviewed clients #2-#3 (C#2 – C#3). (C#2) statements with the Long Beach Police Department were not consistent. (C#2) does not recall the incident on 08/25/23 and claimed that (C#1) did “not” do drugs. (C#2) also denied that (C#1) had passed away. (C#3)’s statements were consistent with what was reported that led to the call for 911 with the Long Beach Police Department. According to (C#3), (C#1) purchased drugs “outside” the facility when (C#1) had access to money. (C#3) was aware of (C#1)’s drug habits and did not witness (C#1) do drugs inside the facility.

Based on the information collected, an inspection of the facility, observation and interviews conducted, and an examination of records reviewed, the investigation did not provide sufficient evidence to substantiate neglect resulting in the death of (C#1). Interviews, police reports, (EMS) reports, and a death certificate indicated that drug overdose was the cause of (C#1)’s unnatural death. Although (C#1) had a history of drug abuse, facility staff did not witness (C#1) having drug paraphernalia, nor did the facility know of warning signs of (C#1)’s drug use in the facility that led to (C#1)’s unnatural death. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation of NEGLECT/LACK OF SUPERVISION, did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator (Rodolfo Dimatulac).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024

LIC9099 (FAS) - (06/04)

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