306005792-6-13-2025-22-AS-AORZ-DKPMA2-20250819092535

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 06/13/2025
Date Signed: 06/13/2025 10:41:37 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/03/2025 and conducted by Evaluator Samer Haddadin

COMPLAINT CONTROL NUMBER: 22-AS-20250603161747

FACILITY NAME:	BLUE SKY MANOR INC		FACILITY NUMBER:	306005792
ADMINISTRATOR:	GABRIEL AIRAPETIAN		FACILITY TYPE:	740
ADDRESS:	280 N WILSHIRE AVE		TELEPHONE:	(714) 844-2667
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	50	CENSUS: 31	DATE:	06/13/2025
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Sona		TIME COMPLETED:	10:35 AM

ALLEGATION(S):

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Facility overcharged residents for care.
Facility did not have a designated staff who is primary responsibility for food planning, preparation and service.
Facility staff allowed residents to use illict drugs on the premises.

INVESTIGATION FINDINGS:

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LPA Samer Haddadin conducted an unannounced 10-day complaint visit and to present findings regarding several reported allegations. Upon arrival, LPA Haddadin was greeted by the Program Director, Sona, who granted full access to the facility. The investigation included a tour of the premises, interviews with staff members, and a thorough review of all records pertaining to the alleged incidents involving resident (R1).
The investigation first addressed the allegation that the facility overcharged residents for care. A review of facility and resident files indicated that R1 was admitted in December 2022 under the CalOptima recuperative care program. R1's monthly out-of-pocket cost was $900.00, while other residents paid between $1,300.00 and $2,800.00. The records also showed that R1 had failed to pay their dues for August and October 2024 and had only made partial payments of $250.00 for both July and September 2024.
CONTINUE ***9099C**

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025

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 22-AS-20250603161747

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BLUE SKY MANOR INC	FACILITY NUMBER: 306005792
	VISIT DATE: 06/13/2025

NARRATIVE

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Regarding the second allegation, which claimed the facility lacked a designated staff member for food services, the investigation found otherwise. During the facility tour, it was observed that food was handled by a certified employee. This individual holds an Accredited Certification issued on May 24, 2024, which remains valid until May 24, 2027.
Finally, the investigation looked into the allegation that facility staff allowed residents to use illicit drugs on the premises. A review of facility records confirmed a policy of conducting random drug tests for all CalOptima residents. Records for tests administered on October 7 and October 8, 2024, showed that all fifteen CalOptima residents tested had negative results.
Therefore, based on the preponderance of evidence gathered through interviews and the review of all pertinent records, the allegation that the " Facility overcharged residents for care. Facility did not have a designated staff who is primary responsibility for food planning, preparation and service. Facility staff allowed residents to use illicit drugs on the premises." was found to be Unfounded. This determination means the allegation was proven to be false, could not have happened, or is without a reasonable basis.
No deficiencies were cited during the visit. An exit interview was conducted with Program Director Sona, who was provided with a copy of this report.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025

LIC9099 (FAS) - (06/04)

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