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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336426495
Report Date: 07/22/2024
Date Signed: 07/22/2024 04:11:23 PM

Document Has Been Signed on 07/22/2024 04:11 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PERRIS BREEZE RESIDENTIAL CAREFACILITY NUMBER:
336426495
ADMINISTRATOR/
DIRECTOR:		MUMBI KAIRUFACILITY TYPE:
735
ADDRESS:3545 BREEZE COURTTELEPHONE:
(951) 251-4575
CITY:PERRISSTATE: CAZIP CODE:
92571
CAPACITY: 6CENSUS: 4DATE:
07/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:05 PM
MET WITH:Khumbuzlie Diamini, House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that four (4) clients reside at this facility; all at Program and there are currently two (2) caregivers present. There is an Infection Control Plan on file.

Client Records-Incident Reports/Clients Rights-Information/Dental- LPA began review of client records. Four (4) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

Personnel Records/Training/and Staffing- LPA began review of employee records- Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 09/15/2024.



Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen.

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SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PERRIS BREEZE RESIDENTIAL CARE
FACILITY NUMBER: 336426495
VISIT DATE: 07/22/2024
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Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 108.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms or bodies of water observed at this home.

Medications- are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.

P&I- was reviewed. LPA observed that the facility maintains a separate log for each individuals’ monies. Money counted count was accurately reflected on the ledger.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Dual smoke detectors with carbon monoxide detectors were tested and found to be operational. Fire extinguisher was recharged last year, 08/18/2023. The facility is conducting emergency disaster/fire drills monthly; last done on 07/06/2024.

Based on the information received during this visit today in the areas reviewed, no deficiency are being cited per Title 22, Division 6 of The California Code of Regulations.

This LIC 809 report was reviewed with the facility representative and a copy was provided.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC809 (FAS) - (06/04)
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