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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004381
Report Date: 07/28/2021
Date Signed: 07/28/2021 05:36:58 PM

Document Has Been Signed on 07/28/2021 05:36 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 IIFACILITY NUMBER:
306004381
ADMINISTRATOR:IRINA MAROUSSENKOFACILITY TYPE:
740
ADDRESS:29631 IVY GLENN DRIVETELEPHONE:
(949) 388-0406
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 4DATE:
07/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Irina MaroussenkoTIME COMPLETED:
05:50 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. Administrator Irina Maroussenko arrived shortly after LPA. LPA and Administrator toured the facility. Facility is a 6 bedroom, 3 bathroom home with a 3 car garage. The garage is kept locked and used for storage. One room is for caregivers and kept locked. LPA observed the locked medication cart. LPA observed the kitchen is clean and organized. 2-day perishable and 7 day non-perishable food supply on hand. Smoke detectors and carbon monoxide detector tested operational. Fire extinguisher is fully charged. All the bedrooms had the required furnishings. LPA inspected the backyard. No bodies of water observed. Pathway to the exit gate is not obstructed by obstacles or hazards. Facility mitigation plan is pending approval. No deficiencies are being cited as a result of todays visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2021
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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