<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 08/08/2024
Date Signed: 08/08/2024 12:29:26 PM

Unsubstantiated


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 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
UNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Sona HakobyanTIME COMPLETED:
12:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff sexually abuses the residents while in care
Staff choked a resident while in care
Staff behavior poses as a risk to the residents
Staff is threatening a resident with eviction
Staff are not meeting the residents dietary needs
Staff are not providing the residents with proper utensils
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 allegations. LPA met with Administrator (AD) Sona Hakobyan and explained the reason for today’s inspection. The investigation into the allegations that staff sexually abuses the residents while in care, staff choked a resident while in care, staff behavior poses as a risk to the residents, staff is threatening a resident with eviction, staff are not meeting the residents dietary needs, and staff are not providing the residents with proper utensils revealed the following: 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, the facility’s menu since January 2024, and Staff #1’s (S1) training records

CONTINUED
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
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: 08/08/2024
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
26
27
28
29
30
31
32
Regarding the allegation that staff sexually abuses the residents while in care: it was alleged that S1 had inappropriate sexual incidents with multiple residents. LPA interviewed seven residents regarding this allegation, five of whom did not corroborate the allegation and had positive things to say about S1. Out of the seven residents interviewed, one resident had an issue in the past with S1, refused to disclose what the issue was, but stated that it had been addressed with AD and resolved properly and quickly. Per AD, this resident had requested that S1 no longer provide care for them but did not disclose the reason and AD stated it is not uncommon for residents to have preferences and requests with regards to which staff provide care. Out of the seven residents interviewed, another resident stated they had interactions with S1 that they felt were inappropriate, but the interactions were only verbal and based on the resident’s own description the resident themselves was a major participant in the interactions. In addition, LPA received information from another resident that the resident involved in these verbal interactions is not trustworthy. LPA interviewed AD who stated that they have not seen S1 engage in improper behavior as alleged. LPA interviewed S1 who denied the allegation. LPA did not obtain information corroborating this allegation.

Regarding the allegation that staff choked a resident while in care: it was alleged that S1 choked a resident with a banana. LPA interviewed nine residents regarding this allegation, five of whom did not provide information about the allegation. One resident reported that S1 “shoved a banana” in their mouth, they were choking, and they do not know why S1 did this. Three residents corroborated this 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. While S1 acted improperly in this situation, the information obtained did not corroborate that S1 choked the resident.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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: 08/08/2024
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
26
27
28
29
30
31
32
Regarding the allegation that staff behavior poses as a risk to the residents: it was alleged that S1 creates an unsafe environment for female residents by being sexually suggestive, flirty, and engaging in inappropriate touching and conversation. LPA interviewed seven residents regarding this allegation, five of whom did not corroborate the allegation and had positive things to say about S1. Out of the seven residents interviewed, one resident had an issue in the past with S1, refused to disclose what the issue was, but stated that it had been addressed with AD and resolved properly and quickly. Per AD, this resident had requested that S1 no longer provide care for them but did not disclose the reason and AD stated it is not uncommon for residents to have preferences and requests with regards to which staff provide care. Out of the seven residents interviewed, another resident stated they had interactions with S1 that they felt were inappropriate, but the interactions were only verbal and based on the resident’s own description the resident themselves was a major participant in the interactions. This resident also stated that S1 says “mi amor” to other residents, is “handsy” with other residents, and hugs and kisses other residents on the forehead. However, no other resident interviewed corroborated any improper behavior by S1. In addition, LPA received information from another resident that the resident involved in these verbal interactions is not trustworthy. LPA interviewed AD who stated that they have not seen S1 engage in improper behavior as alleged. LPA interviewed S1 who denied the allegation. The information obtained is conflicting.

Regarding the allegation that staff is threatening a resident with eviction: it was alleged that residents are threatened with eviction for reporting issues at the facility. LPA interviewed seven residents regarding this allegation and did not obtain information corroborating the allegation. LPA interviewed AD who stated that there are no pending evictions. LPA did not obtain information corroborating this allegation.

Regarding the allegation that staff are not meeting the residents dietary needs: it was alleged that there is no variety in the meals, Mexican food was served for almost all meals for months, the facility does not follow special diets such as vegetarian or diabetic diets, the daily vegetable is potatoes, and the alternative meal is always a sandwich with one slice of cheese or meat. LPA interviewed seven residents regarding this allegation and none of the residents reported major issues with the food or that they had a doctor-ordered diet that was not followed.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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: 08/08/2024
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
26
27
28
29
30
31
32
 One resident reported there is a lot of potatoes, pasta, and beans, while another reported the menu contains a lot of meat. One resident felt the facility serves a little too much Mexican food, while other residents disagreed. LPA inspected the facility, observed lunch to be chicken salad, fruit salad, and green salad which was provided by a catering company, observed residents enjoying the food, and did not observe any resident complaining about the food or asking for an alternative. LPA interviewed AD who stated that the facility follows all doctor-ordered diets and is working with the catering company to improve the variety of foods provided. LPA reviewed the facility’s menu since January 2024 which shows a proper variety of foods. The information obtained is conflicting.

Regarding the allegation that staff are not providing the residents with proper utensils: it was alleged that residents are served food in takeout boxes and on Styrofoam plates due to the catering and lack of dishwashing staff. LPA inspected the facility and observed the facility has a sufficient supply of regular plates, bowls, cups, and utensils and that during lunch residents in the dining room were served with disposable plates and regular cups and utensils while residents eating in their rooms received disposable take-out boxes and disposable utensils. LPA interviewed AD who stated that in the morning the facility uses regular plates and utensils which are cleaned after breakfast by the cook and that for all other meals the facility may use regular or disposable plates and utensils depending on the day. LPA interviewed seven residents all of whom corroborated that the facility mainly disposable plates and utensils, but did not report that this has impacted their enjoyment of the food negatively, although one resident noted it is difficult to eat chicken with a plastic fork but another resident preferred the disposable plates and utensils as they are cleaner and lighter. Per AD, staff have already been advised to offer regular utensils for items that need to be cut, such as meat dishes, to ensure the use of disposable plates and utensils do not limit the residents’ enjoyment of the food. The information obtained is conflicting.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report 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
LIC9099 (FAS) - (06/04)
Page: 4 of 4