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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006085
Report Date: 03/06/2024
Date Signed: 03/06/2024 11:29:34 AM


Document Has Been Signed on 03/06/2024 11:29 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:GOLDEN BREEZE MANORFACILITY NUMBER:
306006085
ADMINISTRATOR:DELOS SANTOS, RAMILFACILITY TYPE:
740
ADDRESS:28891 CALLE JUCATELEPHONE:
(714) 227-6557
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 4DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Christina ValerioTIME COMPLETED:
11:45 AM
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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 Christina Valerio and explained the reason for the visit. Christina Valerio's Administrator's certificate expires on 9/01/2024. The facility is a single story home with 8 bedrooms (2 are for staff only), 6 bathrooms, an office, living/dining room, kitchen, and an attached 3 car garage. LPA and Administrator toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the entry way of the facility. LPA observed all resident rooms have the required furnishings. LPA observed a 2-day perishable and a 7 day non-perishable food supply on hand. The kitchen is clean and organized. LPA observed the refrigerator in the kitchen is operational. LPA observed the stove lights unassisted. Medications and sharp objects are kept secured and inaccessible to residents in the kitchen. The garage is kept locked and used for storage. LPA observed emergency food and water supply stored in the garage. Hot water in all bathrooms measured between 111.0 degrees Fahrenheit and 111.7 degrees Fahrenheit. The carbon monoxide/smoke detectors tested operational. LPA observed all fire extinguishers are fully charged. LPA and Administrator toured the backyard. The backyard has a table with an umbrella and chairs for residents to sit outside. There is a fountain the backyard. The fountain is raised and is five feet tall and poses no risk to residents, The exit gates on each side of the house are operational and self latching. No obstacles or hazards observed inside or outside of the facility. LPA reviewed 4 out of 4 resident files. All of the resident files had the required documents with no deficiencies observed. LPA reviewed all 4 residents medication, no discrepancies observed. LPA reviewed 3 staff files. All staff files had the required documents and no deficiencies observed. LPA inspected the first aid kit, the first aid kit had all the required elements. No citations are being issued as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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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