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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803927
Report Date: 08/09/2022
Date Signed: 08/10/2022 08:44:14 AM

Document Has Been Signed on 08/10/2022 08:44 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BENICIA BREEZEFACILITY NUMBER:
486803927
ADMINISTRATOR:HAYNES, DEANNAFACILITY TYPE:
735
ADDRESS:1445 WEST K STREETTELEPHONE:
(510) 345-8077
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY: 6CENSUS: 0DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:Lamaya LeeTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an annual Required-1 year inspection and met with, facility manager, Lamaya Lee. Deanna Haynes, Administrator was not available during this visit. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. There is currently no clients in care.

LPA toured facility and grounds with Lamaya Lee and observed COVID-19 precaution signs posted in common areas to promote hand washing, wearing a mask and cough etiquette. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for staff, as there are currently no clients and facility has 30-day PPE supply. Facility will follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels. Staff have not been N-95 Fit tested. Facility was found to be at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged and serviced on 8/7/2022. LPA advised facility to remove all other extinguishers from the premises or ensure they have all been serviced, charged and with tags.

LPA consulted with Lamaya Lee regarding the pieces of wood, items and debris that needs to be removed from the outside premises. LPA explained any area accessible to LPA would be accessible to the clients and there should be no hazards. The facility currently has no clients and facility was advised to notify LPA as soon as they have their first client move in.

LPA consulted and requested facility staff to get N95 fit tested and to get the correct size of the PUB475 poster.
Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BENICIA BREEZE
FACILITY NUMBER: 486803927
VISIT DATE: 08/09/2022
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 LPA also requested the following updated records to be submitted to Community Care Licensing by 8/31/2022



· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC 610D Emergency Disaster Plan
Exit interview conducted with Lamaya Lee.


No deficiencies cited during today's inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
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