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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609763
Report Date: 07/22/2024
Date Signed: 08/20/2024 03:10:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/03/2023 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20230703161605
FACILITY NAME:BLUE SKIES RANCHFACILITY NUMBER:
197609763
ADMINISTRATOR:KRAKOVER, EILENEFACILITY TYPE:
740
ADDRESS:6061 SHIRLEY AVETELEPHONE:
(818) 730-4182
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:6CENSUS: 4DATE:
07/22/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Eilene Krakover- AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff administered resident medication without consent
Staff leaves resident in bed for an extended period of time.
Staff left resident in soiled for an extended period of time.
Staff did not provide adequate food service to resident in care.
Facility does not have adequate staff to care for residents.
Staff did not allow resident visitors.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mariana Agban arrived at the facility to conduct an unannounced subsequent complaint investigation based on further information obtained for this complaint. Upon arrival, LPA was greeted by the administrator, and the purpose of the visit was explained. Today's investigation consisted of an interview with the Administrator, and obtaining additional documents.

Allegation: Staff administered resident medication without consent
It was alleged that staff administered Seroquel to R1 from April 20, 2023, to April 23, 2023, without consent from R1's responsible party. Records review and interviews revealed that the administrator didn't notify R1's responsible party regarding R1's change of condition and the new medication prescription. Administrator did administer Seroquel medication on April 20, 2023, before getting consent from the R1 responsible party. Based on information obtained the allegation is deemed Substantiated at this time.
(Conintue on 90099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 31-AS-20230703161605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BLUE SKIES RANCH
FACILITY NUMBER: 197609763
VISIT DATE: 07/22/2024
NARRATIVE
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Allegation: Staff leaves resident in bed for an extended period of time.
It was alleged that Staff left R1 for extended period of time in bed. Interviews with W2 and W6 confirmed that staff left R1 for an extended time. Both direct witnesses confirmed that staff would only move R1 out of bed when there was a visitor in the facility or when W2 requested another staff assistance to move R1 out of the bed. W2 stated that R1 was left alone without food and no changed clothes. The administrator didn't deny the allegation. Based on information obtained the allegation is deemed Substantiated at this time.
Allegation: Staff left resident in soiled for an extended period of time.
It was alleged that staff left R1's soiled in their diapers for an extended period of time. Interview with W2 revealed that the facility is understaffed and thus staff would use multiple diapers on one resident so staff won't change R1 as often. However, Interviews with the Administrator and staff revealed that R1 would never notify them that they need to use the restroom or when they want to change their diaper. R1's medical records indicated that R1 needs assistance with incontinence care. The administrator didn't deny the allegation. Based on information obtained the allegation is deemed Substantiated at this time.
Allegation: Staff did not provide adequate food service to resident in care.
It was alleged that staff left R1 in their dark bedroom without food. The administrator denied the allegation. However, interviews with direct witnesses confirmed that staff did not provide adequate food service to residents in care. W2 stated that R1 stayed until 11:00 AM without breakfast, and staff wouldn't offer an alternative option when R1 did not like the food. W6 noted that residents would eat only one meal daily without any snacks. W6 mentioned that staff would tell residents to wait so they could combine breakfast and lunch meals. Based on information obtained the allegation is deemed Substantiated at this time.
Allegation: Facility does not have adequate staff to care for residents.
It was alleged that facility doesn't have enough staff to meet residents needs. Interviews with direct witnesses revealed that the facility had 4 residents with only one staff and the Administrator. Direct witnesses confirmed that the Administrator would leave the residents with one staff to run errands. W1 stated that the Administrator had called for assistance to left up from the bathroom floor. W2 stated that the facility has been always understaffed and the administrator was aware and didn't act on it. Based on information obtained the allegation is deemed Substantiated at this time.
Allegation: Staff did not allow resident visitors.
It was alleged that Administrator did not allow visitors for R1. RP stated that on 6/21/23, the Administrator asked RP via text message to not visit R1. Although, the Administrator stated that her residents had visitors the other day. The administrator didn't deny the allegation. Based on information obtained the allegation is deemed Substantiated at this time.

Exit interview conducted, citations issued, appeal rights given and a copy of this report delivered
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20230703161605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLUE SKIES RANCH
FACILITY NUMBER: 197609763
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2024
Section Cited
CCR
87468.1(a)(8)
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ยง 87468.1 - Personal Rights of Residents (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidenced by:
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Administrator will email LPA a statement of understanding this section of CCR by the POC date.
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Administrator didn't notify R1's responsible party regarding the new medication perscribed and administred.This pose a potential health & safety risk to the residents in care.
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Type B
08/05/2024
Section Cited
CCR
87464(a)
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(a) The services provided by the facility shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care. Such persons shall be encouraged to participate as fully as their conditions permit in daily living activities both in the facility and in the community.
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Administrator will hire a licensed vendor to train all staff on Basic Services Regualtions. Administrator will email LPA the vendor number, and attendance log. Training and certification must be submitted to the licensing agency by 08/05/24
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This requirement was not met as evidenced by: Based on direct witnesses Staff left R1 in bed for an extended period of time. This pose a potential health & safety risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20230703161605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLUE SKIES RANCH
FACILITY NUMBER: 197609763
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2024
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence (b) (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by:
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Administrator will hire a licensed vendor to train all staff on Managed Incontinence. Administrator will email LPA the vendor number, and attendance log. Training and certification must be submitted to the licensing agency by 08/05/24
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Based on interviews and direct witnesses R1 was left in soiled for an extended period of time. This pose a potential health & safety risk to the residents in care.
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Type B
08/02/2024
Section Cited
CCR
87555(b)(5)
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General Food Services (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents. This requirement was not met as evidenced by:
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Administrator will hire a licensed vendor to train all staff on General Food Services. Administrator will email LPA the vendor number, and attendance log. Training and certification must be submitted to the licensing agency by 08/05/24
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Based on interviews and direct witnesses R1 was left without food or provided an alternative options. This requirement was not met as evidenced by:
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20230703161605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLUE SKIES RANCH
FACILITY NUMBER: 197609763
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/05/2024
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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Administrator will email LPA LIC500 showing adequate staff coverage by the POC date.
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Based on interviews and direct witnesses facility does not have adequate staff to care for residents. This pose a potential health & safety risk to the residents in care.
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Type B
08/05/2024
Section Cited
CCR
87468.1(a)(11)
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To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by:
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Administrator will hire a licensed vendor to train all staff on Personal Rights Regulations. Administrator will email LPA the vendor number, and attendance log. Training and certification must be submitted to the licensing agency by 08/05/24
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Based on information obtained Staff did not allow resident visitors. This pose a potential health & safety risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5