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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005792
Report Date: 03/24/2023
Date Signed: 03/24/2023 04:45:31 PM


Document Has Been Signed on 03/24/2023 04:45 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:BLUE SKY MANOR INCFACILITY NUMBER:
306005792
ADMINISTRATOR:MARY SALCEDOFACILITY TYPE:
740
ADDRESS:280 N WILSHIRE AVETELEPHONE:
(714) 844-2667
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:50CENSUS: 42DATE:
03/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:06 PM
MET WITH:Mary SalcedoTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho conducted a case management visit for the purpose to issue a citation after delivering the findings in connection to complaint control number: 22-AS-20230317083408. LPA met with Administrator (Admin) Mary Salcedo and explained the reason for the visit.

On March 24, 2023 during the complaint visit in connection to complaint control number: 22-AS-20230317083408, LPA interviewed Staff (S1) in person and Staff 2 (S2) by telephone. LPA observed during the staff file review that Staff 1 (S1) and Staff 2 (S2) were not reflected on the Personnel Report Summary via the Licensing Information System (LIS) dated March 22, 2023. On today's date at 1:40pm and 1:41pm, LPA observed via the Department's Guardian Background Check that S1 and S2 were fingerprint cleared but not associated to the facility which the Admin acknowledged. Per review of records, S1 was employed on August 17, 2022 and on July 12, 2021 for S2. Per Title 22 Regulation 87355 Criminal Record Clearance, facility is required to request a transfer criminal record clearance prior to working at the facility, therefore the preponderance of evidence standard has been met.

Based on observations, interviews conducted, and the records reviewed, a deficiency is being cited per Title 22 Division 6 Chapter 8 of the California Code of Regulations. See LIC809D. An immediate CIVIL PENALTY (LIC421BG) is assessed.

An exit interview was conducted with Administrator Mary Salcedo, and a copy of this report along with the LIC811, LIC809D, LIC421BG, and the appeal rights were provided during this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
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 03/24/2023 04:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2023
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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Licensee agrees to associate two staff and to provide proof to LPA via email by POC due date.
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This requirement is not met as evidenced by: Based on observations, interviews, and record review, two of two staff were not associated prior to working at the facility which poses an immediate Health, Safety, or 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: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
LIC809 (FAS) - (06/04)
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