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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006085
Report Date: 02/19/2025
Date Signed: 02/19/2025 04:49:11 PM

Document Has Been Signed on 02/19/2025 04:49 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GOLDEN BREEZE MANORFACILITY NUMBER:
306006085
ADMINISTRATOR/
DIRECTOR:		DELOS SANTOS, RAMILFACILITY TYPE:
740
ADDRESS:28891 CALLE JUCATELEPHONE:
(714) 227-6557
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 5DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:34 PM
MET WITH:Cristina ValerioTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Cristina Valerio and explained the reason for the visit. Cristina Valerio's Administrator's certificate expires on September 1, 2026. The facility 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. Facility is licensed for 6 non-ambulatory residents and a hospice waiver for 6. LPA and Administrator toured the facility. LPA observed the See Something, Say Something sign posted in the main entry way of the facility. LPA observed the kitchen is clean and organized. The 4 burner gas stove lights unassisted. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed a 3 day emergency supply of food and water in the garage. LPA observed medications are kept locked in the kitchen pantry. LPA observed the first aid kit has all the required elements. LPA toured the resident bedrooms and bathrooms. Smoke detectors/carbon monoxide detectors tested operational. The last emergency drill was conducted November 21, 2024. LPA observed all resident bathrooms are clean and operational. Hot water measured 115.1 degrees Fahrenheit in all bathrooms. LPA observed all resident rooms had the required furnishings. LPA toured the backyard. The backyard has a seating area with an umbrella and chairs for the residents. There is a small fountain in the backyard. Both exit gates are operational. LPA reviewed staff files. All staff members are background cleared and associated to the facility. All staff members have the required training including CPR training. LPA reviewed 6 resident records and medications. No discrepancies observed. No discrepancies are being cited as a result of this visit. LPA consulted with the Administrator concerning reporting requirements. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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