306005792-5-16-2026-22-AS-APAO-DU94A8-20260519185531

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 05/16/2026
Date Signed: 05/16/2026 04:53:11 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
02/27/2023 and conducted by Evaluator Samer Haddadin

COMPLAINT CONTROL NUMBER: 22-AS-20230227162125

FACILITY NAME:	BLUE SKY MANOR INC		FACILITY NUMBER:	306005792
ADMINISTRATOR:	MARY SALCEDO		FACILITY TYPE:	740
ADDRESS:	280 N WILSHIRE AVE		TELEPHONE:	(714) 844-2667
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	50	CENSUS: 41	DATE:	05/16/2026
		UNANNOUNCED	TIME BEGAN:	08:17 AM
MET WITH:	Gabriel Airapetian		TIME COMPLETED:	04:19 PM

ALLEGATION(S):

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1-Facility is not following COVID-19 Guidelines
2-Facility is not providing adequate food service
3-Facility does not have a menu
4-Facility is not providing activities to residents
5-Facility does not allow residents to select their own pharmacies

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced site visit to the facility to investigate and deliver findings regarding the above-mentioned allegations. Upon arrival, Administrator (AD) Gabriel Airapetian greeted LPA, granted entry into the facility, and was informed of the purpose of the visit.
During the course of the investigation, LPA conducted a health and safety walk-through of the facility, observed the physical plant, reviewed relevant facility records, and conducted interviews with four staff members and four residents.
Regarding the allegation that “Facility is not following COVID-19 Guidelines,” During the health and safety walk-through, LPA observed the facility to be clean, orderly, and sanitary. Common areas, resident rooms, restrooms, and dining areas were observed to be maintained without any immediate health and safety concerns. {***CONTINUE***90999C}

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2026

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 3

Control Number 22-AS-20230227162125

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: 05/16/2026

NARRATIVE

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LPA observed that infection control supplies were available at the facility, including hand soap, paper towels, and cleaning supplies. LPA reviewed the Infection Control Plan for the facility and saw it to be up-to-date. Also, four out of four Staff interviewed denied the allegation and stated that the facility offers masks when asked and housekeeping carries out routine cleaning. Four out of four residents interviewed did not report concerns regarding the facility’s infection control practices or COVID-19 precautions
Regarding the allegation that “Facility is not providing adequate food service,” LPA conducted a review of facility, documentation, observations, and interviews. During the investigation, LPA reviewed facility invoices dated February 27, 2026, which confirmed that food services are provided by an outside catering vendor. The vendor prepares meal courses, including breakfast, lunch, and dinner, directly at the facility. The facility also employs full-time kitchen staff who assist the vendor with meal preparation and food service. LPA reviewed Food Handler Certificates for relevant staff, which were observed to be active and valid until April 1, 2029. During the health and safety walk-through, LPA observed residents eating breakfast that was consistent with the scheduled menu. The meal observed consisted of yogurt with granola and berries, with additional options of scrambled eggs and ham. Four out of four staff interviewed denied the allegation and stated that residents are consistently provided meals of adequate quality and quantity. Staff also stated that residents have access to snacks and beverages throughout the day and may request meal alternatives if they do not prefer the scheduled meal option. All four Residents interviewed denied concerns regarding food quality, portion size, meal availability, or the facility’s ability to provide regular meals.
Regarding the allegation that “Facility does not have a menu,” LPA reviewed facility records and observed the facility’s posted menu during the visit. During the record review, LPA confirmed that the facility maintains an active and structured menu. LPA also observed that residents were being served in a manner consistent with the facility’s posted menu and food service practices. All four staff interviewed denied the allegation and stated that the facility maintains a menu for resident meals.{***CONTINUE***90999C}

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20230227162125

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: 05/16/2026

NARRATIVE

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Also, all four residents interviewed did not report concerns regarding the facility not having a menu, and no evidence was obtained to show that the facility failed to maintain or follow a menu.
Regarding the allegation that “Facility is not providing activities to residents,”. Four out of four Staff interviewed denied the allegation and stated that residents are offered activities based on their interests, abilities, and participation preferences. Staff reported that activities may include socialization, television, music, games, and other resident-centered activities. Four out of four residents interviewed denied concerns regarding the facility failing to provide activities and did not report that they were prevented from participating in activities. During the visit, LPA did not observe any immediate concerns related to resident engagement or lack of access to activities. LPA also observed that the facility has a dedicated room designed for residents’ activities which has a large TV puzzles and other activity supplies.
Regarding the allegation that “Facility does not allow residents to select their own pharmacies,” all four Staff interviewed denied the allegation and stated that residents, responsible parties, or authorized representatives may select a pharmacy of their choice. Staff further stated that the facility may provide pharmacy information or coordination assistance only when requested; however, residents are not required to use a specific pharmacy. LPA reviewed 4 residents’ files and observed that all four have different pharmacies from one another. Also, all four Residents interviewed did not report being denied the right to choose their own pharmacy and did not express concerns. Based on observations, interviews, and records reviewed, the Department is unable to determine whether the above allegations occurred as reported. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove or disprove that the alleged violations occurred. Therefore, the allegations are deemed unsubstantiated.
An exit interview was conducted with Administrator (AD) Gabriel Airapetian. A copy of this report was discussed with and provided to AD Gabriel Airapetian at the conclusion of the visit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2026

LIC9099 (FAS) - (06/04)

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