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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005792
Report Date: 08/08/2024
Date Signed: 08/08/2024 04:07:25 PM


Document Has Been Signed on 08/08/2024 04:07 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 INCFACILITY NUMBER:
306005792
ADMINISTRATOR:SONA HAKOBYANFACILITY TYPE:
740
ADDRESS:280 N WILSHIRE AVETELEPHONE:
(714) 844-2667
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:50CENSUS: 46DATE:
08/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Sona HakobyanTIME COMPLETED:
12:25 PM
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This unannounced Case Management – Other inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering amended findings for Complaint Control No. 22-AS-20240514210454. LPA met with Administrator (AD) Sona Hakobyan and explained the reason for today’s inspection.

During the inspection, LPA and AD reviewed and discussed the previously delivered report and the amended report and LPA delivered the amended report to AD.

An exit interview was conducted and copies of this report and the amended report were discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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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