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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004380
Report Date: 07/21/2022
Date Signed: 07/25/2022 01:42:00 PM


Document Has Been Signed on 07/25/2022 01:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:PACIFIC BREEZE HOMEFACILITY NUMBER:
306004380
ADMINISTRATOR:IRINA MAROUSSENKOFACILITY TYPE:
740
ADDRESS:29511 ANA MARIA LANETELEPHONE:
(949) 366-9367
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 5DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Irina MaroussenkoTIME COMPLETED:
12:42 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Staff called the Administrator (AD) Irina Maroussenko who arrived and was present for the visit.

At 11:10 AM LPA Haley began the tour of the facility with AD Maroussenko. Near the front door LPA Haley observed a screening station with hand sanitizer, a temperature log sheet, and a temperature thermometer. In the closet near the front door there was a fax machine and staff files. All required posting were observed on the wall through out the facility.

There were five clients present for the visit. All client bedrooms were clean, well organized, and had all necessary requirements. Both client bathrooms were clean and organized. Hot water temperature was measured at 119.4 degrees Fahrenheit in client bathroom #1 and 119.6 degrees Fahrenheit in client bathroom #2. LPA Haley observed a locked medication cart in the staff bedroom. In a hallway closet a supply of linen was observed.

The garage and laundry areas are kept locked and inaccessible to residents at all times. The garage was clean and organized. All hazardous chemical are stored in the garage. LPA Haley observed an emergency supply of food and water stored in the garage. LPA Haley observed a supply of additional PPE in the garage and an extra supply of clean linen. A fully charged and mounted fire extinguisher was mounted on the wall.

The kitchen was clean and organized. All knives and sharp objects were locked in a lock box. All burners on the stove were operational. The facility has a two day supply of perishable food items and seven day supply of nonperishable food items.


Continued on LIC 809 C

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: PACIFIC BREEZE HOME
FACILITY NUMBER: 306004380
VISIT DATE: 07/21/2022
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The backyard was clean, organized, and free of clutter. There was a side exit gate that was self closing and self latching. In the backyard, LPA Haley observed a shaded area with a table and chairs.

No bodies of water were observed during today's visit.

All smoke detectors were tested and are operational. No deficiencies are being cited during todays visit. An exit interview conducted and a copy of the report was provided to the Administrator Irina Maroussenko.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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