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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803927
Report Date: 07/17/2023
Date Signed: 07/24/2023 04:27:32 PM

Document Has Been Signed on 07/24/2023 04:27 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BENICIA BREEZEFACILITY NUMBER:
486803927
ADMINISTRATOR:HAYNES,DEANNA&LEE,LAMAYAFACILITY TYPE:
735
ADDRESS:1445 WEST K STREETTELEPHONE:
(510) 345-8077
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY: 6CENSUS: 0DATE:
07/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:42 PM
MET WITH:Jonathan Germany, care staffTIME COMPLETED:
04:28 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an annual Required-1 year inspection and met with Care staff, Jonathan Germany. LPA spoke with Administrator, Lamaya Lee by phone.. Deanna Haynes, Administrator was not available during this visit. This facility is licensed for 6 ambulatory clients.

LPA toured facility and grounds with Jonathan Germany and observed the home to be clean at a comfortable temperature with all exits free from obstruction.
Smoke detectors and carbon monoxide detectors are operational, LPA requested removal of 1 additional carbon monoxide detector that was none operational or to ensure that it is working if the carbon monoxide detector is to remain on the wall. The fire extinguisher located in the kitchen was observed charged and there was a receipt for proof of purchase on August 7, 2022. Facility had additional fire extinguishers and LPA requested removal of extra extinguishers or proof that they have been serviced. Bedrooms were observed with the required furnishings, 1 bedroom was not set up, but there was a bed an additional items to set up the room. 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 went over requirements once they get their first client, at this time individual living in the home, identified as i1, provided LPA with their ID and i1 is fingerprint cleared and associated to this facility.

Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2023
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: 07/17/2023
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Administrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit the current following documents by 8/21/2023:
· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610 Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)

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

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC809 (FAS) - (06/04)
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