306005792-10-24-2024-22-AS-MSTC-DAJ6BM-20241029204012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 10/24/2024
Date Signed: 10/24/2024 04:15:21 PM

Unsubstantiated

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
09/12/2024 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240912115747

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:	10/24/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Gabriel Airapetian- Finance Manager		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Staff require residents to purchase medications from a particular pharmacy.
Staff did not ensure resident's medication was available at the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of continuing the investigation and delivering the findings into the above allegations.

On September 17, 2024, LPAs Jessica Cho and Edward Kim initiated the 10-day complaint investigation. LPAs interviewed six out of eight residents and two staff however interviews were denied by the two residents. Pertinent documentations were obtained such as the Resident Roster, Staff Roster, Face Sheets, six out of eight residents’ Medication Administration Records (MARs) and Physician’s Reports or Medical Records. On September 25, 2024, LPA Cho continued the investigation and obtained additional records such as the Resident Roster, Narcotic Inventory Sheet, and Recuperative Care Program Policy and Procedures. Subsequent interviews were conducted with the two staff and one additional staff. On today’s date, LPA continued the interviews with two staff and obtained additional records such as the Narcotic Inventory Sheet, R1’s medical discharge summaries, and Resident’s Pharmacy Assignment List.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

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-20240912115747

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: 10/24/2024

NARRATIVE

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The investigation revealed the following: It is alleged that the staff requires residents to purchase medications from a particular pharmacy. One out of six residents and one out of the three staff confirmed the allegation stating that the facility recommends certain pharmacies and feels like the resident have to. However, six out of the six residents stated that they are not coerced, persuaded, or influenced to change pharmacy. Residents are informed and recommended to utilize any one of the three pharmacies (PH1, PH2, and PH3) facility works with. It was reported that out of the three pharmacies, residents are encouraged to utilize PH3. Per review of the resident roster obtained on today’s date, 46 residents reside at the facility. Out of the 46 residents, 24% of the residents utilize PH1, 20% with PH2, 32% with PH3, and 24% with various other pharmacies. Based on the evidence obtained, although 32% of the residents are using PH3, there are other pharmacies that residents are utilizing, therefore LPA is unable to corroborate the allegation.

Regarding the allegation, Staff did not ensure resident’s medication was available at the facility, the investigation revealed the following: One out of the six residents and two out of three staff corroborated with the allegation during the interview stating that the PRN medication for Resident #1 (R1), Oxycodone and Acetaminophen, also known as Percocet, was not available at the time when it was needed. Per the doctor’s order for Percocet, R1 can take one tablet by mouth every 8 hours as needed. Based on the review of Narcotic Inventory Sheet from July 27, 2024, to September 25, 2024, the log documents R1 receiving Percocet on a daily basis three times per day. R1 received the last remaining tablet of Percocet at 2:48am on August 5, 2024. In a text message responded by Finance Manager (FM) Gabriel Airapetian, on August 5, 2024 at 5:57pm, the medication was being delivered by R1’s pharmacy. The inventory documents R1 receiving their second dose when the medication was delivered at 10:00pm that same day. Although R1 did not receive Percocet for close to 20 hours, it is determined based on the evidence obtained that the facility made an effort to ensuring that the medication was being delivered on time. Three out of the three staff confirmed that the delivery of medications can be delayed by R1’s pharmacy due to inventory issues.

Therefore, based on the interviews which were conducted and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegations: Staff require residents to purchase medications from a particular pharmacy and Staff did not ensure resident’s medication was available at the facility is deemed UNSUBSTANTIATED. Administrator Sona Hakobyan authorized LPA to conduct an exit interview with Finance Manager Gabriel Airapetian prior to her leave, and a copy of this report was provided at exit to Finance Manager Airapetian.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC9099 (FAS) - (06/04)

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