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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004380
Report Date: 07/02/2024
Date Signed: 07/02/2024 11:54:34 AM


Document Has Been Signed on 07/02/2024 11:54 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
ORANGE COUNTY RO, 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:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Irina MaroussenkoTIME COMPLETED:
12:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Irina Maroussenko and explained the reason for the visit. The facility is a six bedrooms (1 is for staff) house with 2 bathrooms, kitchen, dining room, living room and an attached two car garage. LPA and the Administrator toured the facility. LPA observed the PUB 475 poster posted in the entry way of the facility. The garage is kept locked and used for storage. Smoke detectors and the carbon dioxide detector tested operational. The fire extinguisher mounted in the dining room is fully charged. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed knives are kept locked in a box on the kitchen counter. LPA observed the fireplace in the living room is screened. LPA and the Administrator toured the resident bedrooms. All resident bedrooms were clean and organized. All the resident bedrooms had the required furniture and bed linens. LPA observed both bathrooms are clean and operational. Hot water measured 106.1 degrees Fahrenheit in both bathrooms. LPA observed medication is kept locked in a medication cart kept in the staff bedroom. LPA and the Administrator toured the backyard. No bodies of water observed. There is a covered patio with chairs for residents to sit outside. The exit gate is operational. No obstacles or hazards observed in the backyard. LPA reviewed 5 resident files and medications. No discrepancies observed. LPA reviewed 2 staff files, no discrepancies observed. Both staff members had the required 20 hours of annual training. Both staff members had current CPR training. LPA observed the Administrator did not have a current Administrator's certificate. LPA observed the facility has WiFi but does not have a device for resident use. LPA interviewed staff and residents. No obstacles or hazards observed inside the facility. LPA observed the first aid kit had all the required elements. Deficiencies are being cited per title 22 Division 6 of the California Code of Regulations on the attached LIC 809D. An exit interview was conducted with the Administrator and a copy of the report provided along with appeal rights.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
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 07/02/2024 11:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: PACIFIC BREEZE HOME
FACILITY NUMBER: 306004380

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
All facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above, the Administrator does not have a current valid certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Licensee agrees to hire a certified Administrator with a valid Administrator's certificate or to complete the requirements to be issued an Administrator's Certificate from the Agency.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
LIC809 (FAS) - (06/04)
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