306005792-4-30-2024-22-AS-SHAD-D4TS3V-20240430133146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005792
Report Date: 04/30/2024
Date Signed: 04/30/2024 01:31:59 PM

Document Has Been Signed on 04/30/2024 01:31 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BLUE SKY MANOR INC		FACILITY NUMBER:	306005792
ADMINISTRATOR:	SONA HAKOBYAN		FACILITY TYPE:	740
ADDRESS:	280 N WILSHIRE AVE		TELEPHONE:	(714) 844-2667
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	50	CENSUS: 48	DATE:	04/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Sona Hakobyan		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Sona Hakobyan and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 10:00AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a large commercial facility. Facility is a 25-bedroom, 27-bathroom, 1 story building. There is a courtyard in the middle and a covered patio in the back with patio covers for the residents. Resident Bedrooms: the 7 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 7 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 112 degrees F and 122 degrees in the 7 resident bathrooms inspected, prior to corrections. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the housekeeping room. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have been paid. At about 11:00AM, LPA reviewed 7 resident files and 5 staff files, interviewed 5 residents and 5 staff, and inspected medications for 7 residents. Facility does not handle resident money. CONTINUED

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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 04/30/2024 01:31 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BLUE SKY MANOR INC	FACILITY NUMBER: 306005792
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(c)

Infection Control Requirements

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, the facility does not have an Infection Control Plan, which poses a potential health risk to persons in care.
	POC Due Date: 05/28/2024
	Plan of Correction
1 2 3 4	Licensee stated they will review Provider Information Notice (PIN) 22-18-ASC, as well as related PINs, and submit the Infection Control Plan to LPA by POC due date.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, the licensee did not ensure the files of S1, S2, S4, and S5 contained documentation of the required number of hours and topics of annual training, which poses a potential health risk to persons in care.
	POC Due Date: 05/28/2024
	Plan of Correction
1 2 3 4	Licensee stated they will complete and document all required annual training for these staff and submit proof to LPA by POC due date.

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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/30/2024 01:31 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BLUE SKY MANOR INC	FACILITY NUMBER: 306005792
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, the licensee's last emergency disaster drill was almost 4 months ago (not quarterly) and only involved 2 out of 3 shifts, which poses a potential safety risk to persons in care.
	POC Due Date: 05/28/2024
	Plan of Correction
1 2 3 4	Licensee stated they will conduct emergency disaster drills for all 3 shifts and submit proof to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 INC	FACILITY NUMBER: 306005792
	VISIT DATE: 04/30/2024

NARRATIVE

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During the inspection, LPA and AD observed the following: based on documents, the facility does not have an Infection Control Plan; based on documents, the licensee did not ensure the files of S1, S2, S4, and S5 contained documentation of the required number of hours and topics of annual training; based on documents, the licensee's last emergency disaster drill was almost 4 months ago (not quarterly) and only involved 2 out of 3 shifts. A technical violation for water temperature was issued and the water heaters were adjusted down during the inspection.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC809 (FAS) - (06/04)

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