306005792-1-15-2021-22-AS-JALE-BXANN8-20210115093620

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005792
Report Date: 01/13/2021
Date Signed: 01/15/2021 09:37:23 AM

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 INC		FACILITY NUMBER:	306005792
ADMINISTRATOR:	PETROSYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	280 N WILSHIRE AVE		TELEPHONE:	(714) 844-2667
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	50	CENSUS: 14	DATE:	01/13/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Anna Petrosyan		TIME COMPLETED:	11:15 AM

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	Licensing Program Analyst (LPA) Joseph Alejandre contacted Anna Petrosyan via iPhone to conduct the prelicensing inspection via FaceTime due to Covid-19 precautionary measures. The facility is currently being used by Orange County as a temporary shelter for clients waiting for placement in a new facility. The County's Lease and operation of the building will cease 1/15/2021. The new facility will be licensed as an RCFE with a capacity of 50. The Fire Clearance has been approved by Anaheim Fire Department, fire inspector Alicia Badosa, on 12/11/2021. The application was received by CCL on 2/26/2020. Facility phone number is 714-844-2667. Applicant Anna Petrosyan toured the facility via FaceTime with LPA Alejandre. Structure; Facility is a one story building with 25 resident rooms, recreation room with TV, dining room and kitchen, laundry room, medication room and administration offices. Bedrooms Residents. All resident rooms have their own bathroom and are shared rooms for 2 residents. LPA observed that all rooms had a night stands, wall mounted lamps and a shared closet. LPA observed none of the rooms had chairs for residents. Facility telephone number is 714-844-2667. Bathrooms. were clean, faucets and toilets were operational, grab bars secure and showers had no slip mats. Water temperature measured 120 degrees Fahrenheit. Linens & Hygiene Supplies. new linens were observed. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. seven days nonperishable food supply and two day perishable food supply reviewed. LPA inspected the Kitchen and Dining room. Both were clean and free of hazards. Carbon Monoxide, Smoke Detectors, Fire Extinguishers were observed. All monitors tested during fire clearance inspection and are operational. Toxins: cleaning supplies were kept locked in a storage closet and is inaccessible to residents. Medication room is kept locked and only accessible to staff. First-Aid Kit & Activity Supplies. observed and available. Resident & Staff Files no clients at this time. No files reviewed. LPA observed an outdoor patio area with seating for residents. LPA observed the following, 1. LPA observed that there were no chairs in the resident rooms. 2. LPA observed there was no ombudsman sign listing the phone number for the local ombudsman and there was no sign CCL complaint sign, PUB 475, also known as the "See Something, Say Something" poster. Items were discussed with Applicant Anna Petrosyan. Applicant agreed to correct the both of the items listed and to notify the LPA when they are corrected to schedule the next visit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2021

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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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
	VISIT DATE: 01/13/2021

NARRATIVE

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During the visit LPA Alejandre explained the process of this application and also about the post licensing visit once the facility is licensed. Applicant was informed the items listed above (no chairs in resident rooms, ombudsman sign, CCL complaint sign) must be completed in order for the facility to meet Title 22 Division 6 of the California Code of Regulations. Second Pre-Licensing visit is required to complete the Pre-Licensing inspection.

Applicant was informed today that the final approval will be processed by the CAU supervisor in Sacramento.

Component III was waived during the visit due to applicant is a current licensee for a licensed RCFE facility and in compliance status, supervisor approved.

An exit interview was conducted and a copy of this report, LIC809 was explained and provided to applicant Anna Petrosyan via email, electronic read receipt confirms applicant receiving the report.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2021

LIC809 (FAS) - (06/04)

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