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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609763
Report Date: 08/18/2023
Date Signed: 08/18/2023 02:19:41 PM


Document Has Been Signed on 08/18/2023 02:19 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



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: 2DATE:
08/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Eilene Krakover- AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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In conjunction to complaint control 31-AS-20230703161605 LPAs Agban and Cava conducted a case management deficiencies visit to address facility's Centrally Stored Medication Log During the course of investigating complaint control 31-AS-20230703161605. It was revealed that the facility is not updated with their Centrally Stored Medication Log. Based on this discovery, citation will be issued on the LIC 809 D. A copy of this report is issued and Appeal of Rights is given.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
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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Document Has Been Signed on 08/18/2023 02:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2023
Section Cited
CCR
87208(a)

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Plan of Operation: Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. This requirement was not met as evidenced by:
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As POC, the administrator agrees to keep and maintain their LIC 622 for all facility residents. Copies of each resident's LIC 622 will be submitted to LPA by 08/25/23
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Review of the facility's medication policy indicates that the facility will maintain their LIC 622 Centrally Stored Medications up to date. Licensee failed to demonstrate their plan of operation pertaining to medications, which can 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.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
LIC809 (FAS) - (06/04)
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