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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006085
Report Date: 03/21/2022
Date Signed: 03/21/2022 09:32:16 AM

Document Has Been Signed on 03/21/2022 09:32 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:
03/21/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Christina Valerio, Ramil Delos SantosTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to conduct the second pre-licensing visit. LPA was greeted and checked for symptoms of Covid-19. LPA was granted entry by staff. LPA met with applicants. Christina Valerio, Ramil Delos Santos.

The following items have been corrected; 1. The ceiling fan in Bath 1 has been replaced and is operational. 2. The stove has been replaced and is operational, all 4 burners light unassisted. No deficiencies observed. The facility is ready to be licensed.

During the visit LPA Alejandre explained the process of this application and also about post licensing visit once the facility is licensed.

Applicant was informed today that the final approval will be processed by the CAB supervisor in Sacramento.

Component III was waived during the visit due to applicant is a current licensee for a licensed RCFE facility and in compliance status, supervisor approved.

An exit interview was conducted and a copy of this report, LIC809 was explained and provided to applicant.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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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