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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 03/18/2025
Date Signed: 03/18/2025 03:03:07 PM

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
01/27/2025 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250127111244
FACILITY NAME:BLUE SKY MANOR INCFACILITY NUMBER:
306005792
ADMINISTRATOR:SONA HAKOBYANFACILITY TYPE:
740
ADDRESS:280 N WILSHIRE AVETELEPHONE:
(714) 844-2667
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:50CENSUS: 45DATE:
03/18/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Sona Hakobyan- Administrator
Gabriel Airapetian- Finance Manager		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Unlawful eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of continuing the complaint investigation into the above allegation. LPA was greeted and granted entry by Administrative Assistant (AA) Sonya Tatunts. Administrator (Admin) Sona Hakobyan arrived approximately 9:00am and Finance Manager (FM) Gabriel Airapetian around 11:00am.

On January 27, 2025, the Department received the complaint regarding the unlawful eviction of the Short-Term Post Hospitalization House (STPHH) residents under the Recuperative Care Program (RCP) regulated by a different entity. The complaint was initiated by LPA on January 29, 2025. During the course of the investigation, LPA interviewed seven residents and four staff and obtained pertinent documentation which includes the Resident Rosters, Personnel Reports, Face Sheets, Medical Records, Eviction Notices/rescinded Eviction Notice, and Plan of Operations.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
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 3
Control Number 22-AS-20250127111244
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: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2025
Section Cited
CCR
87224(a)-(i)
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87224 Eviction Procedures (a)-(i)

This requirement was not met as evidenced by:
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Administrator stated that they will provide a copy of 87224 and a written notice to all current STPHH residents rescinding the initial notice issued on or around 1/24/25 and a meeting will be conducted with all residents discussing the eviction procedures and will obtain signatures from residents attending the meeting. A copy of the attendance sheet will be emailed to LPA by POC due date.
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Based on the interviews and record review, facility did not issue valid eviction notices to STPHH residents which poses a potential Health, Safety, and/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.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250127111244
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
VISIT DATE: 03/18/2025
NARRATIVE
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Regarding the allegation, Unlawful eviction, it was reported that the STPHH residents are unlawfully evicted by the facility. The investigation revealed the following: Based on the random review of the records of seven residents, two residents are under RCP and five with the STPHH. Five out of the seven residents interviewed confirmed receiving an eviction notice on or around January 24, 2025 and refused to move out. As of today's date, three STPHH residents moved out after receiving the eviction notices which was corroborated by three out of three staff. At this time, facility is not in compliance with the regulatory requirements outlined in the Title 22, Eviction Procedures, as the eviction notices did not include but is not limited to the following: the effective date/reason for the eviction, current service plan, relocation evaluation, list of referral agencies, seeking approval from the Department, and etc.

Therefore, based on the interviews which were conducted and the records that was reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Unlawful eviction is deemed SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations.

An exit interview was conducted with Administrator Sona Hakobyan and Finance Manager Gabriel Airapetian who was present on the telephone call, and a copy of this report including the LIC9099-C & D, and appeal rights were provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3