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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005792
Report Date: 01/15/2021
Date Signed: 01/15/2021 09:49:54 AM

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:BLUE SKY MANOR INCFACILITY NUMBER:
306005792
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:280 N WILSHIRE AVETELEPHONE:
(714) 844-2667
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:50CENSUS: 14DATE:
01/15/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rochel Malaca, Assistant AdministratorTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Joseph Alejandre contacted Rochel Malaca via iPhone to conduct the second prelicensing inspection via FaceTime due to Covid-19 precautionary measures. LPA Alejandre toured the facility with Assistant Administrator Rochel Malaca. LPA observed the ombudsman sign with the phone number for the local ombudsman and the "See Something, Say Something" Poster, PUB 475, were both posted in the entry hallway. LPA observed each resident room now has 2 chairs, one for each resident in all of the rooms. The facility has complied with Title 22 regulations. Facility is now ready for licensure. LPA explained to the Assistant Administrator that the final approval will be given by the CAB specialist in Sacramento. Component III has been waived because the Administrator/Applicant has 2 other licensed facilities. An exit interview was conducted and a copy of this report was provided to Rochel Malaca, Assistant Administrator, via email, an electronic read receipt confirms receipt of the report.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2021
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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