306005792-3-24-2023-22-AS-SSAS-CQE2QH-20230329173558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 03/24/2023
Date Signed: 03/24/2023 04:02:07 PM

Unsubstantiated

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
03/17/2023 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230317083408

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: 42	DATE:	03/24/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Mary Salcedo		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

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Residents personal rights are being infringed upon.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose to investigate into the above allegation. At 10:23am, LPA Cho met with Adminstrator (Admin) Mary Salcedo and stated the purpose of the visit. During the course of the investigation, LPA obtained and reviewed records pertinent to Resident 1 (R1), conducted interviews with (2) residents, (1) staff, Program Coordinator (PC) Sona Hakobyan and Admin Salcedo. The following was determined: It was alleged that the residents personal rights are being infringed upon. It was reported that medical assessments of three residents were conducted in the dining room on February 21, 2023 while residents were having their meals. Three out of five individuals interviewed observed seeing the House Doctor (HD) who is not employed under the facility was seen talking to a resident in the dining room on February 21st, however it was determined that only one out of five individuals confirmed that the HD asked confidential medical questions in front of other residents. Due to conflicting statements, LPA is unable to corroborate the allegation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 22-AS-20230317083408

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: 03/24/2023

NARRATIVE

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Based on the interviews conducted and the records reviewed, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the above allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted with Administrator Mary Salcedo, and a copy of this report and the LIC811 were provided during this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
03/17/2023 and conducted by Evaluator Jessica Cho

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230317083408

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: 42	DATE:	03/24/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Mary Salcedo		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

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Facility staff did not safeguard the residents' belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit for the purpose to investigate into the above allegation. At 10:23am, LPA Cho met with Adminstrator (Admin) Mary Salcedo and stated the purpose of the visit. During the course of the investigation, LPA obtained and reviewed records pertinent to Resident 1 (R1) and conducted interviews with (1) staff, Program Coordinator (PC) Sona Hakobyan, and Admin Salcedo. The following was determined: It was alleged that the facility staff did not safeguard the residents' belongings. It was reported that R1's porkloin went missing. Three out of four individuals interviewed confirmed that the porkloin was stolen from the kitchen refrigerator and all three were unable to identify the person in question. Therefore, the preponderance has been met.
Based on the interviews conducted and the records reviewed, the above allegation is deemed SUBSTANTIATED. A deficiency is being cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations. See LIC9099D. An exit interview was conducted with Administrator Mary Salcedo, and a copy of this report along with the LIC9099C, LIC9099D, LIC811, and the appeal rights were provided during this visit.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20230317083408

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: 03/24/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/31/2023 Section Cited CCR 87218(a)(2)	1 2 3 4 5 6 7	87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in Section 1569.153.	1 2 3 4 5 6 7	Licensee agrees to receive residents' signatures for their understanding of the faciity's theft and loss policy and to forward proof to LPA by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews, three of four individuals confirmed the meat was stolen which poses a potential Health, Safety, or Personal Rights risk to persons 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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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