306004381-7-21-2022-22-AS-JHAY-CGJTH7-20220721144417

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004381
Report Date: 07/21/2022
Date Signed: 07/21/2022 02:44:26 PM

Document Has Been Signed on 07/21/2022 02:44 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 HOME II		FACILITY NUMBER:	306004381
ADMINISTRATOR:	IRINA MAROUSSENKO		FACILITY TYPE:	740
ADDRESS:	29631 IVY GLENN DRIVE		TELEPHONE:	(949) 388-0406
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY:	6	CENSUS: 3	DATE:	07/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Irina Maroussenko		TIME COMPLETED:	02:55 PM

NARRATIVE

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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 Administrator (AD) Irina Maroussenko and explained the reason for the visit.

At 1:16 PM LPA Haley began the tour of the facility with AD Maroussenko in the kitchen. LPA Haley observed The kitchen was clean and organized. All knives and sharp objects were locked in a lock box. The facility has a two day supply of perishable food items and seven day supply of nonperishable food items. A fully charged and mounted fire extinguisher was mounted on the wall. Around 1:18 PM LPA Haley observed two of the burners on the stove would not light without assistance.

There were three residents present for the visit. All resident bedrooms were clean, well organized, and had all necessary requirements. Resident bathrooms were clean and organized. Hot water temperature was measured at 108.8 degrees Fahrenheit in resident bathroom #1, 111.5 degrees Fahrenheit in resident bathroom #2, and 111.5 degrees Fahrenheit in resident bathroom #3. LPA Haley observed a locked medication cart in the staff bedroom. In a hallway near the resident rooms LPA observed a laundry room that remains locked and inaccessible to residents.

LPA Haley observed a cabinet near the front door with a fax machine, staff files, and a first aid kit with all required elements.

The garage is locked and inaccessible to residents at all times. The garage was being used for storage space, and walkways were clear and free of tripping hazards. All hazardous chemical are stored in the garage on a shelf. LPA Haley observed an emergency supply of food and water. Further, a supply of PPE, and plenty of extra linens was observed in the garage and.

Continued on LIC 809 C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 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)

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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 II	FACILITY NUMBER: 306004381
	VISIT DATE: 07/21/2022

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The backyard had clear walkways, free of tripping hazards. 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. While walking through the back yard LPA Haley observed various materials being used for the home construction being done on the property.

No bodies of water were observed during today's visit. All smoke detectors were tested and are operational.

Deficiencies are being cited during todays visit. An exit interview conducted and a copy of the report and appeal rights were provided to Administrator Irina Maroussenko.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 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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Document Has Been Signed on 07/21/2022 02:44 PM - 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PACIFIC BREEZE HOME II	FACILITY NUMBER: 306004381
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87305(a)(b)

Alterations to Existing Building or New Facilities: 87305 (a) Prior to construction or alteration, all facilities shall obtain a building permit. (b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to the health and safety exists. This requirement is not met as evidenced by observation of constrution work being done, construction tools and materials, and confimation from Administrator Maroussenko that construction has been underway for about two months.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/29/2022
	Plan of Correction
1 2 3 4	Administrator Maroussenko will provide a building permit and new floor plan/facility sketch (LIC 200) if nessary. Administrator will also consult with her LPA Joseph Alejandre for further instructions.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

LIC809 (FAS) - (06/04)

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