306005792-9-12-2022-22-AS-AJLO-CJUTA6-20221003143259

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 09/12/2022
Date Signed: 09/12/2022 01:22:16 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/08/2022 and conducted by Evaluator Sean Haddad

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220908172450

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: 41	DATE:	09/12/2022
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Mary Salcedo		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility has an insect infestation

INVESTIGATION FINDINGS:

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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above identified complaint allegation. LPA met with Administrator (AD) Mary Salcedo and explained the reason for today’s inspection. The investigation into the allegation that Facility has an insect infestation revealed the following: During the course of the investigation, LPA interviewed AD and residents and requested and reviewed copies of the resident roster, staff roster, and pesticide records.

LPA inspected the facility and observed handful of flying insects in the hallways of the facility. LPA observed the backdoor leading to the outside smoking section open with insects flying around the smoking section. AD stated that the backdoor should remain closed, but that residents regularly leave it open when they go in and out. LPA observed a large open-air central patio with a doorway and multiple windows connected to the hallways of the facility. The doorway does not have a door and the windows do not have glass. There are rollable tarps/blinds covering all of these openings, but large gaps remain that cannot be closed.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220908172450

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/12/2022

NARRATIVE

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In addition to the rollable tarps/blinds, LPA observed larger blue tarps draped over the rollable tarps/blinds, but gaps still remain that cannot be closed. Due to the openings to the central open-air patio, as well as doors that are left open, insects are getting into the building. LPA interviewed 6 residents, 4 of whom stated the facility has an insect infestation. AD stated that the facility has always had a pest control company come spray every 2 months. AD stated that the building owner stated they will begin a project to close off the open-air central patio openings using plexiglass in January 2023. In the meantime, AD stated that in response to recent issues with mosquitos, the facility has taken and plans to take the following steps: arranged for Orange County to come spray for mosquitos on 09/09/22; will arrange for Orange County to come spray for mosquitos again at the earliest opportunity; request additional visits from the facility’s pest control company; request additional measures, including bug lights, from the facility’s pest control company.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220908172450

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/26/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee has already had Orange County spray for mosquitos and has developed a plan to permanently close off the open-air central patio. In addition, Licensee stated they will continue to have the insects addressed by their pest control company and Orange County and will explore additional measures with their pest control company. POC CLEARED.
	8 9 10 11 12 13 14	Based on observations and interviews, the licensee did not prevent insects from getting into the facility and causing an infestation, which poses a potential personal rights and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC9099 (FAS) - (06/04)

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