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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 12:45:19 PM


Document Has Been Signed on 08/08/2024 12:45 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 - DeficienciesUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Sona HakobyanTIME COMPLETED:
01:00 PM
NARRATIVE
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This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20240514210454. LPA met with Administrator (AD) Sona Hakobyan and explained the reason for today’s inspection.
During the course of the investigation, LPA inspected the facility, conducted health and safety checks on the residents, interviewed AD, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, and Staff #1’s (S1) training records. LPA interviewed nine residents regarding a report that S1 had choked a resident with a banana while in care, five of whom did not provide information about the report. One resident corroborated that S1 “shoved a banana” in their mouth, they were choking, and they do not know why S1 did this. Three residents corroborated the report, two of whom were direct witnesses. The two direct witnesses stated that, while the resident was in the dining room, the resident began coughing and gasping for air but was not choking, S1 tried to pat them on the back and then went to get a banana and tried to put the banana in the resident’s mouth against their will multiple times, and that they do not know why S1 did this. LPA interviewed AD who stated that they were informed of the incident by residents, they reviewed video footage of the incident, they observed S1 trying to assist the resident but did not see the banana, but they immediately suspended S1 pending investigation of the incident. LPA interviewed S1 who admitted the report, stating it was an emergency situation and they tried to put the banana in the resident’s mouth in order to help them because they believed eating something would help the resident clear their throat. LPA reviewed S1’s training records and confirmed S1 has current CPR, first aid, and caregiver training. However, the evidence obtained corroborated that S1 acted improperly in this situation and violated the resident’s personal rights.
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 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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Document Has Been Signed on 08/08/2024 12:45 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: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2024
Section Cited
CCR
87468.1(a)(1)

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87468.1 Personal Rights … (a) … (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Licensee stated that S1 has been terminated as of 05/20/24. During the inspection, LPA confirmed that S1 has been disassociated from the facility on Guardian. POC CLEARED.
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Based on interviews, the licensee did not ensure a resident was accorded dignity when S1 attempted to put a banana into a resident’s mouth against their will when they were having respiratory issues, which poses an immediate personal rights risk to persons in care.
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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 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
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