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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 04/27/2023
Date Signed: 04/27/2023 06:31:52 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
04/21/2023 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230421090353
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: 43DATE:
04/27/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mary SalcedoTIME COMPLETED:
06:33 PM
ALLEGATION(S):
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Facility staff did not administer medications as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to begin the investigation into the allegations listed above. LPA met with Administrator Mary Salcedo and explained the reason for the visit. The investigation into the allegation facility staff did not administer medication as prescribed revealed the following. It was alleged that Resident 1's (R1) medications were not administered as prescribed. The facility had a medication administration record (MAR) for R1 for March 2023. Staff reported medication was administered as prescribed. Witnesses reported medication was not administered as prescribed. The MAR for March 2023 shows the resident was not administered 5 medications on 10 different days with no explanation as to why they were missed. Based on information gathered through record review and interviews the preponderance of evidence standard has been met, therefore, the allegation, facility staff did not administer medications as prescribed, is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report along with citation and Appeal Rights (LIC 9058 01/16) was provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
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 5
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
04/21/2023 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230421090353

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: 43DATE:
04/27/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mary SalcedoTIME COMPLETED:
06:33 PM
ALLEGATION(S):
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2
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9
Facility required resident to use facility’s doctor.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to begin the investigation into the allegations listed above. LPA met with Administrator Mary Salcedo and explained the reason for the visit. The investigation into the allegation, facility required resident to use facility's doctor revealed the following. It was reported that R1 was required by the facility to change doctors. Facility staff reported that all residents are allowed to keep their doctor and no one is required to switch. A review of records dated from 12/12/22, 1/31/23 and 4/27/23 show R1's primary care physician has not changed and is the same physician R1 reported as their primary care physician before they moved into the facility. Based on the evidence gathered the allegation, facility required resident to use facility’s doctor, is deemed unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of the report provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/21/2023 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230421090353

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: 43DATE:
04/27/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sona Hakobyan, Mary SalcedoTIME COMPLETED:
06:33 PM
ALLEGATION(S):
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9
Facility did not follow medication destruction procedures.
Facility required resident to use facility’s pharmacy.
Unlawful eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to begin the investigation into the allegations listed above. LPA met with Administrator Mary Salcedo and explained the reason for the visit. The investigation into the allegation, facility did not follow medication destruction procedures, revealed the following. It was alleged the facility threw away R1's medication after they left the facility. LPA toured the medication room with staff. Medication for Resident 1 (R1) was not present at the facility. 3 out of 3 staff interviewed reported that medication is never thrown away and it is given back to the pharmacy for disposal. Staff reported that R1 was provided their medication when they left the facility. There is no documentation to prove R1 signed for and took their medication when they left the facility. Based on the evidence gathered the allegation, facility did not follow medication destruction procedures is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Regarding the allegation, unlawful eviction. It was reported the facility would not let Resident 1 (R1) return after their hospital stay.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
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 5
Control Number 22-AS-20230421090353
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: 04/27/2023
NARRATIVE
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Staff reported that R1 had family take their personal belongings out of their shared room and informed the facility they were not returning. LPA inspected R1's former shared room and the current residents residing in the room verified all of the belongings in the room are their personal items. R1 reported that they did not inform staff they were not returning to the facility. All witnesses interviewed reported that an eviction notice was not issued. Based on the evidence, the allegation, unlawful eviction, is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Regarding the allegation, Facility required resident to use facility’s pharmacy, the investigation revealed the following. It was alleged the facility required R1 to use their preferred pharmacy. Staff reported all residents are free to choose any pharmacy they wish. A review of records show residents use 6 different pharmacies. There is no record as to what pharmacy R1 used. There is no record that R1 changed to the facilities preferred pharmacy. No evidence was gathered that supports the allegation. Based on the evidence the allegation, facility required resident to use facility’s pharmacy, is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20230421090353
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: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2023
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
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Licensee to ensure all medications are given in accordance to doctor's orders at all times. Licensee to submit a written statement to LPA indicating they have read this section of regulation and how they intend to adhere by providing staff training. Licensee to provide proof to LPA POC due date.
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based on record review and interview the Licensee did not ensure the medications for R1 were given according to physician's orders. R1 was not administered 5 medications on 10 different days. This poses an immediate risk to the health & safety of residents 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: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5