197609763-9-9-2024-31-AS-TAGD-D9TRUM-20241007132006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609763
Report Date: 09/09/2024
Date Signed: 09/09/2024 03:23:10 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
02/28/2024 and conducted by Evaluator Gina Saucedo

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240228152538

FACILITY NAME:	BLUE SKIES RANCH		FACILITY NUMBER:	197609763
ADMINISTRATOR:	KRAKOVER, EILENE		FACILITY TYPE:	740
ADDRESS:	6061 SHIRLEY AVE		TELEPHONE:	(818) 730-4182
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	6	CENSUS: 4	DATE:	09/09/2024
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Eilene Krakover		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff leave bedridden resident alone in the facility while in care
Staff do not ensure that resident is able to reach them to request assistance as necessary

INVESTIGATION FINDINGS:

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On 09/09/24, at 9:50am, Licensing Program Analyst (LPA) Gina Saucedo and Angelica Segovia arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Administrator, Eilene Krakover. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint.

On 03/05/2024, Licensing Program Analyst (LPA) Tuesday Cabiness initiated the complaint investigation. On 09/09/24, LPA Saucedo and LPA Segovia asked for the census, staff, and resident rosters. On 09/09/24, LPA Saucedo interviewed additional staff and residents, conducted a physical tour, gathered additional information, and delivered findings.

LIC 9099C-continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240228152538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLUE SKIES RANCH	FACILITY NUMBER: 197609763
	VISIT DATE: 09/09/2024

NARRATIVE

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Regarding the allegation: Staff leave bedridden resident alone in the facility while in care. It is being alleged that the resident is left in bed all day. LPA's interviewed four (4) out of four (4) residents that confirmed that they are not left in bed all day and/or alone in the facility while in care. LPA's also confirmed with resident #2 (R2) who is bedridden if they are left alone in the facility while in care and R2 stated, "no, staff is always here." LPA's interviewed two (2) staff that confirmed that residents are able to leave their room whenever they want and ask for assistance if they want to leave their room and our never left alone in the facility. During the visit, LPA's were able to confirm that there were two (2) staff present and working. Therefore, based on the LPA's records review, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time.

Regarding the allegation: Staff do not ensure that resident is able to reach them to request assistance as necessary. It is being alleged that there is no way of communication between staff and resident for help. LPA's interviewed four (4) out of four (4) residents that confirmed they can request help at any time and as necessary. LPA confirmed with resident #2 (R2) who is bedridden the means of requesting assistance and R2 stated, "I have a bell." LPA's interviewed two (2) staff that confirmed they regular check in with the residents to see if they need any assistance. During the visit, LPA's observed assistance being provided to the residents. Therefore, based on the LPA's records review, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time.

An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

LIC9099 (FAS) - (06/04)

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