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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005792
Report Date: 03/18/2025
Date Signed: 03/18/2025 03:57:24 PM

Document Has Been Signed on 03/18/2025 03:57 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BLUE SKY MANOR INCFACILITY NUMBER:
306005792
ADMINISTRATOR/
DIRECTOR:		SONA HAKOBYANFACILITY TYPE:
740
ADDRESS:280 N WILSHIRE AVETELEPHONE:
(714) 844-2667
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 50CENSUS: 45DATE:
03/18/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:01 PM
MET WITH:Sona Hakobyan- AdminstratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho continued the visit after delivering the findings in connection to Complaint Control #: 22-AS-20250127111244. LPA explained the purpose of this subsequent visit to Administrator (Admin) Sona Hakobyan.

During the visit, LPA obtained copies of two Plan of Operations, and reviewed records of three residents under the Short Term Post Hospitalization Program (STPHH). Based on the review of the records, facility did not maintain complete records such as the Admission Agreement and Personal Rights in Privately Operated Residential Care Facilities for the Elderly (LIC613C-2). According to Admin Hakobyan, Admission Agreements are not provided under the Recuperative Care and STPHH Programs as residents are admitted to the facility for a short term stay.

Therefore, based on observations, interview, and record review, a deficiency is being cited per Title 22 Division 6 Chapter 8 of the California Code of Regulations. See LIC809D.

An exit interview was conducted with Administrator Sona Hakobyan, and a copy of this report along with the LIC811, LIC809D, Title 22 Regulations 87506 & 87507, and the appeal rights were provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
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 03/18/2025 03:57 PM - It Cannot Be Edited


Created By: Jessica Cho On 03/18/2025 at 03:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2025
Section Cited
CCR
87506(a)

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
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Administrator stated that all CCL required forms will be completed and maintained for all STPHH and Recuperative Care residents moving forward and will either also complete missing forms for current residents OR close the program per the licensee's decision by POC due date.
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Based on observation, interview, and record review, facility did not maintain complete records in three out of three residents which poses a potential 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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
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