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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 06/13/2025
Date Signed: 06/13/2025 11:14:16 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
05/22/2025 and conducted by Evaluator Samer Haddadin
COMPLAINT CONTROL NUMBER: 22-AS-20250522090334
FACILITY NAME:BLUE SKY MANOR INCFACILITY NUMBER:
306005792
ADMINISTRATOR:GABRIEL AIRAPETIANFACILITY TYPE:
740
ADDRESS:280 N WILSHIRE AVETELEPHONE:
(714) 844-2667
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:50CENSUS: 31DATE:
06/13/2025
UNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:SonaTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Unlawful eviction.
Staff is deliberately not submitting residents paperwork to appropriate agency causing a delay in processing required paperwork
INVESTIGATION FINDINGS:
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LPA Samer Haddadin conducted an unannounced complaint visit to present findings regarding two 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 addressed the following allegations:
First, regarding the allegation of an "unlawful eviction," a review of facility records was conducted. No record of the facility issuing any type of eviction notice to Resident 1 (R1) was found. Furthermore, during an interview with LPA Haddadin, R1 admitted that the facility had not given them any written or verbal eviction notice.
Second, regarding the allegation that "staff is deliberately not submitting residents' paperwork to the appropriate agency, causing a delay in processing," a record review
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)
Page: 1 of 2
Control Number 22-AS-20250522090334
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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 was also performed. It was noted that the facility had submitted a claim to CalOptima on behalf of R1. This claim resulted in a denial of benefits due to the depletion of all of R1's available benefits.
Therefore, based on the preponderance of evidence gathered through interviews and record reviews, the allegations of "unlawful eviction" and "staff deliberately not submitting residents' paperwork to the appropriate agency causing a delay" were found to be Unfounded. An unfounded determination means the allegations were determined to be false, could not have happened, and/or are without a reasonable basis.
No deficiencies were cited during today's visit. An exit interview was conducted with the Program Director, and a copy of this report was provided.
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)
Page: 2 of 2