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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006085
Report Date: 03/07/2022
Date Signed: 03/07/2022 11:56:21 AM

Document Has Been Signed on 03/07/2022 11:56 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, 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: 6DATE:
03/07/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Christina Valerio, Ramil Delos SantosTIME COMPLETED:
12:10 PM
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Licensing Program Analysts (LPAs) Joseph Alejandre and Jessica Cho made an announced visit to conduct the pre-licensing inspection. LPAs were screened for Covid-19 symptoms and granted entry. LPAs met with applicant, Cristina Valerio and Ramil Delos Santos. Facility is to operate a Residential Care Facility for the Elderly (RCFE). Capacity is for 6 non-ambulatory residents. Application was submitted to CCL on 09/23/2021. At 9:20 am, LPAs and applicants toured the facility. LPAs observed the following: Structure. This is a single story home with 8 bedrooms, 6 bathrooms, an office, living/dining room, kitchen, and an attached 3 car garage. Garage is being used for storage of food and supplies and is inaccessible to residents. Two of the bedrooms are for caregivers. There is a back yard with a seating area with an umbrella and chairs for the residents. There is a small water fountain in the backyard with no water but small stones in it. Because of the lack of water, the fountain does not pose a hazard to residents in care. Both exit gates on the sides of the facility are latched and operational. No obstacles or hazards observed in the backyard. Facility telephone number is (949) 503-4119. Facility has submitted a COVID-19 Mitigation Plan to CAB and it has been approved. Residents' Bedrooms. The residents' bedrooms are spacious and will easily accommodate the resident's furnishings. All residents' bedrooms had the required furnishings. Each resident had their own room. Bathrooms. All 6 bathrooms are clean and operational. LPAs observed in Bath 1, the ceiling fan did not work. All grab bars were secure and all showers had slip mats. Linens & Hygiene Supplies. All linens were clean and in good repair. Facility had enough hygiene supplies to accommodate all residents. Emergency Phone Numbers, Exit Plan, & Menu: LIC610E reviewed and approved. Food Service. Seven days nonperishable and 2 days perishable food supplies on hand. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: Carbon monoxide and smoke detectors were tested operational. LPAs tested the smoke detectors in each room. Fire extinguisher located in the kitchen was inspected on August 20, 2021 and is fully charged. Appliances. LPAs observed that one out of four burners could not light unassisted. Microwave oven is clean. Refrigerator and freezer is clean and operational. Knives: LPAs observed knives were locked away in a kitchen drawer. Toxins: LPAs observed toxins locked away in the cabinet located in the garage. Water, LPAs measured the hot water in all 6 bathrooms. Continuted on LIC809C.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2022
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GOLDEN BREEZE MANOR
FACILITY NUMBER: 306006085
VISIT DATE: 03/07/2022
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Temperature measured 116.0 degrees Fahrenheit to 120.5 degrees Fahrenheit. Medication LPAs observed medication is kept locked away in the kitchen cabinet. First-Aid Kit & Activity Supplies. LPAs observed the First Aid Kit had all the required elements. LPAs observed board games and the television in the living room. LPAs observed each resident room had their own television. Resident & Staff Files Change of ownership. No files reviewed. Fire clearance was approved by the Orange County Fire Authority by Inspector Francisco Rivera Martinez on 01/21/22.

The following items must be corrected prior to licensure. 1. The ceiling fan in Bath 1 must be repaired/replaced, 2. stove burner 1 must be repaired or the stove replaced. The items listed above must be corrected by 3/18/22. Applicants agreed to repair/replace items by 3/18/22.

Applicants were informed today that the final approval will be processed by the CAB supervisor in Sacramento.

Component III was waived during the visit due to applicants are current licensees for a licensed RCFE facility and in compliance, supervisor approved.

An exit interview was conducted and a copy of this report, LIC809, was explained and provided to both applicants.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
LIC809 (FAS) - (06/04)
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