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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 08/04/2026
Date Signed: 08/05/2026 06:35:47 AM

Substantiated


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
07/30/2026 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260730143439
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: 45DATE:
08/04/2026
UNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Sonya TatuntsTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint received July 30, 2026. LPA Haley was greeted by staff and explained the reason for the visit upon entry.
Regarding the allegation: Unlawful eviction
During the investigation it was discovered, Resident 1 (R1) was sent to the hospital on July 29, 2026, due to having unwitnessed falls. According to hospital staff, after R1 was evaluated there were no signs of multiple falls. The resident was fine and ready to be discharged the same day. When the facility was contacted, R1 was not allowed to return. Hospital staff were informed by Administrator Airapetian that R1’s bed was taken and hospital staff were told that R1 did not want to return to the facility.
Based on the evidence gathered during interviews, and document review the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. A violation is being cited per California Code of Regulations Title 22.
An exit interview was conducted, and a copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
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 2
Control Number 22-AS-20260730143439
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2026
Section Cited
CCR
87224(a)
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87224 (a)Eviction Procedures -
The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty days written notice to the resident is required...This requirement was not met as evidenced by:
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Administrator Airapetian will read and review the regulation section on Eviction Procedures and send a signed statement of acknowledgment and understanding to LPA Haley by 4:00pm on the POC due date (8.5).
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Based on interview confirmation, Resident (1) was not allowed to come back to the facility after being sent to the hospital on July 29, 2026. R1 was discharged from the hospital the same day July 29, 2026. R1 was not allowed to return to the facility.
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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: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
LIC9099 (FAS) - (06/04)
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