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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 06/15/2026
Date Signed: 06/15/2026 04:41:04 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
04/23/2026 and conducted by Evaluator Garlli Tat
COMPLAINT CONTROL NUMBER: 22-AS-20260423123841
FACILITY NAME:BLUE SKY MANOR INCFACILITY NUMBER:
306005792
ADMINISTRATOR:GABRIEL AIRAPETIANFACILITY TYPE:
740
ADDRESS:280 N WILSHIRE AVETELEPHONE:
(714) 844-2667
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:50CENSUS: 43DATE:
06/15/2026
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Janet WalleyTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Medication not administered as prescribed.
Facility staff does not follow resident's prescribed diet.
Facility is not clean.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit to the facility to deliver the findings on the above allegations. LPA met with authorized representative Janet Walley and explained the purpose of the visit.
An initial complaint investigation visit took place on May 1, 2026. During the visit, LPA accompanied by staff, conducted a tour of the facility's physical plant. LPA requested and obtained resident records for Resident 1 (R1). A subsequent visit was held on May 28, 2026. Five staff and five resident interviews were conducted during the visit.
Regarding the allegation that Medication is not administered as prescribed, the following has been concluded: LPA interviewed 5 residents including R1. 3 out 5 residents reported no issues with their medication. R1 reported they believed they had medication issues but could not provide any details and were unsure of the medications they were currently taking.
Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
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-20260423123841
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: 06/15/2026
NARRATIVE
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The other resident interviewed (Resident 3) reported that they were unsure of what medications they were currently prescribed and could not tell the LPA how many different medications they were taking. A review of R1’s medications and MAR for April 2026 shows R1 received their 13 routine medications as prescribed except when R1 was not at the facility. R1 is prescribed 5 PRN medications which they did not request (R1 verified this information). R1 attends dialysis three times per week, which accounts for the discrepancy in the MAR. Five out of five staff reported medication is always administered as prescribed. LPA reviewed the medications and MAR (April 2026) for Resident 2, Resident 3, Resident 4 and Resident 5, no discrepancies observed.

Regarding the allegation that Staff does not follow resident’s prescribed diet, the following has been concluded: A review of records shows R1’s Physician’s report dated April 7, 2026, that R1 is prescribed a low carbohydrate diabetic diet. Staff 1 reported that R1 has been prescribed a renal diet, but there is no documentation to support this report. Staff 1 reported R1 does not follow their prescribed diet and eats whatever they want. Staff 1 reported that they have attempted to talk to R1 about their diet, but R1 will not discuss it with them. R1 is on dialysis three times a week. R1 reported they are not on a renal diet; they are on a diabetic diet. Staff 1 reported that many of the residents at the facility are diabetic, so the facility menu is based on a low carbohydrate diabetic diet. Five out of five staff interviewed confirmed that R1 refuses to eat food served by the facility due to personal preferences. R1 reported they do not like the food at the facility and it is bland and usually served cold. R1 reported they prefer to eat out and eat what they want.

Regarding the allegation Facility is not clean, the following has been concluded: It was reported that R1’s bathroom was not clean and had blood stains on the sink. Four out of the five residents interviewed expressed their satisfaction with the facility staff cleaning the rooms and bathrooms on a regular basis. One resident stated that their roommate was not always neat but denied that it was due to staff negligence because they stated their bathroom gets cleaned regularly. R1 reported that their room is clean but wanted help cleaning their wheelchair. R1 reported that their bathroom is clean. Four out of Four staff reported cleaning is done everyday in the facility and rooms are checked and cleaned when needed. LPA observed during the initial 10-day visit the facility and resident rooms and bathrooms were clean. LPA observed some residents were disorganized, but their rooms were clean.

Continued on LIC 9099-C.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20260423123841
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: 06/15/2026
NARRATIVE
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Based on the evidence gathered during the investigation, the allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted and a copy of the present report was provided to a facility representative.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3