306005792-8-8-2024-22-AS-MSTC-D8NLXY-20240831090928

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 05/23/2024
Date Signed: 08/08/2024 12:11:22 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/14/2024 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240514210454

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: 46	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Sona Hakobyan		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff do not provide adequate food service

INVESTIGATION FINDINGS:

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This is an amended report

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Sona Hakobyan and explained the reason for today’s inspection. The investigation into the allegation that staff do not provide adequate food service revealed the following: During the course of the investigation, LPA inspected the facility, conducted health and safety checks on the residents, interviewed AD and residents, and obtained and reviewed copies of the resident roster, staff roster, and the facility’s food service protocols.

CONTINUED

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240514210454

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/23/2024

NARRATIVE

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Regarding the allegation that staff do not provide adequate food service: it was alleged that there are no dedicated meal servers, all caregivers are asked to serve food during meal times with no one covering caregiving duties, there is concern about cross-contamination of food since caregivers are putting on and removing gloves repeatedly as they juggle resident care needs and food service, the facility does not have a full time chef and the chef only supervises breakfast and snacks, and the facility uses catering for lunch and dinner. LPA interviewed seven residents regarding this allegation and did not obtain information corroborating the allegation. LPA interviewed AD who denied the allegation and stated that during meals there are two kitchen staff inside the kitchen plating food, two caregivers inside the dining room serving the residents, two caregivers making the rounds to provide care to residents along with a medication technician, and that staff do not switch between providing care and serving food in order to prevent cross-contamination. LPA inspected the facility and LPA’s observations did not corroborate the allegation. Regarding cross-contamination, LPA reviewed the facility’s food service protocols which contain the facility’s procedures for preventing cross-contamination which include the sanitation procedure to be followed if a staff member were to provide food service after providing care to residents. Per AD, staff are trained on the facility’s food service protocols and either an extra caregiver is assigned to work in the dining room and kitchen the entire day or the caregiver would start their day working in the dining room and kitchen and then switch to providing care afterwards. However, AD admitted that between March 30, 2024 and May 14, 2024, the facility did not have a full time chef as required.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

This is an amended report

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20240514210454

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B CCR	1 2 3 4 5 6 7	This page was amended due to this first citation being created in error.	1 2 3 4 5 6 7
	8 9 10 11 12 13 14		8 9 10 11 12 13 14
Type B 05/24/2024 Section Cited CCR 87555(b)(17)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b) … (17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service… This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee has already hired a full-time chef and LPA confirmed. POC CLEARED
	8 9 10 11 12 13 14	Based on interviews, the licensee did not ensure the facility had a full-time chef for over a month, which poses a potential health risk to persons in care.	8 9 10 11 12 13 14

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: 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

LIC9099 (FAS) - (06/04)

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