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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 12/28/2023
Date Signed: 12/28/2023 10:06:49 AM

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
09/06/2022 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220906103537
FACILITY NAME:BLUE SKY MANOR INCFACILITY NUMBER:
306005792
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:280 N WILSHIRE AVETELEPHONE:
(714) 844-2667
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:50CENSUS: 46DATE:
12/28/2023
UNANNOUNCEDTIME BEGAN:
07:55 AM
MET WITH:Sona HakobyanTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Staff failed to provide adequate food service
Resident's hygiene needs are not being met
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation(s). LPA met with Administrator (AD) Sona Hakobyan and explained the reason for today’s inspection.

The investigation into the allegations of staff failed to provide adequate food service and resident's hygiene needs are not being met revealed the following: During the course of the investigation, LPA inspected the facility, interviewed the former administrator and seven residents, and obtained and reviewed copies of the Resident Roster, Staff Roster, Photographs of the Facility, Menus, and the House Rules.

Regarding the allegation that the staff failed to provide adequate food service: It was alleged that the facility did not have any ice and served warm water to residents, that the facility does not have a cook, and that every day the facility serves sandwiches and does not serve hot meals or provide snacks.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
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 6
Control Number 22-AS-20220906103537
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: 12/28/2023
NARRATIVE
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LPA interviewed the former administrator who denied that the ice machine was broken, but acknowledged the facility does sometimes run out of ice due to the large amount of ice used by the facility. LPA inspected the facility and confirmed that the ice machine did work, but found little ice in the machine. The former administrator stated that the facility has three cooks total and hired a new chef who is working on a new menu, but was unable to provide a copy of the recent menu for the month. Per the former administrator, the menu includes sandwiches, but also hot food as well as salads and vegetables. The facility provides three meals a day plus snacks, the snacks include fruit and sandwiches, residents are asked if they want snacks and there is also a sign advertising the snacks, and snacks are available at all times and the kitchen does not close. LPA interviewed seven residents, four of whom corroborated that the food is too often cold sandwiches or, if it is a hot food item, it is cold by the time they receive the food.

Regarding the allegation that a resident's hygiene needs are not being met: It was alleged that a resident’s clothes and hands smell like cigarettes and that this resident’s hygiene needs are not being met as they rarely shower. LPA interviewed the former administrator who stated that some residents are independent, some need oversight, and some need care with showers. Residents that need showers get regular showers and that if the former administrator smells an odor, they will direct staff to provide a shower to the resident and/or clean the room as necessary. However, residents can refuse showers and all the facility can do is encourage them. The former administrator denied that any resident has regular hygiene issues and stated that rooms are regularly cleaned to prevent odors. One out of seven residents corroborated that their hygiene needs are not being met, stating that they have only received two showers in almost two months, that they request showers and get appointments for showers, but that staff never show up to provide the shower. LPA observed a strong odor coming from this resident and confirmed this resident’s hygiene needs are not being met.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations that staff failed to provide adequate food service and resident's hygiene needs are not being met. The preponderance of evidence standard has been met; therefore, the above allegations are 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 LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20220906103537
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: 12/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/29/2023
Section Cited
CCR
87464(f)(1)
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87464 Basic Services … (f) Basic services shall at a minimum include: (1) Care and supervision... This requirement was not met as evidenced by:
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The licensee stated that they have since initiated a shower log which documents whether showers were provided or refused in order to ensure residents are receiving their scheduled showers. During the inspection, LPA reviewed the shower log and confirmed the correction. POC CLEARED.
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Based on observation and interviews, the licensee did not ensure 1 out of 7 residents received care and supervision when their hygiene needs were not met, which poses an immediate health risk to persons in care.
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Type B
01/11/2024
Section Cited
CCR
87555(b)(5)
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87555 General Food Service Requirements … (b) … (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for … food habits of residents. This requirement was not met as evidenced by:
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The licensee stated the ice machine has been replaced and the menu has been redone and now contains mainly hot foods and few sandwiches. During the inspection, LPA confirmed these corrections.
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Based on interviews, the licensee did not ensure an appropriate variety of food when the food served was too often a sandwich or otherwise cold, which poses a potential personal rights risk to persons in care.
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The licensee stated they will create a tray service protocol to ensure food is delivered still hot to residents who do not eat in the dining room and will submit proof to LPA by POC due date.
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 LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
09/06/2022 and conducted by Evaluator Sean Haddad
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220906103537

FACILITY NAME:BLUE SKY MANOR INCFACILITY NUMBER:
306005792
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:280 N WILSHIRE AVETELEPHONE:
(714) 844-2667
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:50CENSUS: 46DATE:
12/28/2023
UNANNOUNCEDTIME BEGAN:
07:55 AM
MET WITH:Sona HakobyanTIME COMPLETED:
10:20 AM
ALLEGATION(S):
1
2
3
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9
Staff failed to provide a comfortable environment for residents
Facility is in disrepair
INVESTIGATION FINDINGS:
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation(s). LPA met with Administrator (AD) Sona Hakobyan and explained the reason for today’s inspection.

The investigation into the allegations of staff failed to provide a comfortable environment for residents and facility is in disrepair revealed the following: During the course of the investigation, LPA inspected the facility, interviewed the former administrator and seven residents, and obtained and reviewed copies of the Resident Roster, Staff Roster, Photographs of the Facility, Menus, and the House Rules.

Regarding the allegation that the staff failed to provide a comfortable environment for residents: It was alleged that that the facility’s air conditioning is not working, the facility is too hot, and that some residents are uncomfortable from the smell of cigarettes caused by other residents smoking outside.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20220906103537
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: 12/28/2023
NARRATIVE
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LPA interviewed the former administrator who denied that the air conditioning was broken and stated that this was recently confirmed by a technician. LPA inspected six resident rooms as well as the kitchen, dining room, and common areas and observed the air conditioning was working and that these areas were at a comfortable temperature. The former administrator stated that smoking is only allowed in the smoking area per the house rules, that the facility has about 10 smokers, that some residents complain about the smell of smoke, but that the smokers always follow the house rules by smoking in the designated smoking area and the facility is looking into additional measures to address the concerns of other residents regarding the smell. LPA inspected the facility and observed the smell of cigarette smoke in the hallway closest to the designated smoking area when the door was open, but not in any resident rooms or common areas. LPA interviewed seven residents, none of whom corroborated that the air conditioning was broken. One out of seven residents complained about the smell of smoke, but that resident had left their window open to the designated smoking area. While some smoke smell enters the building when adjacent windows or doors are opened, residents are allowed to smoke and LPA obtained no information indicating residents are violating the house rules in regards to the designated smoking area or that the facility is otherwise uncomfortable.

Regarding the allegation that the facility is in disrepair: It was alleged that a resident room flooded. LPA interviewed the former administrator who reported that two or three toilets were recently broken, but denied that there were any floods. LPA inspected the facility and did not observe anything broken or in disrepair. Six out of seven residents interviewed reported no issues with things being broken. One resident reported that their bathroom flooded, but that the facility promptly fixed it and cleaned the floor and the resident had no complaints about how the facility handled the repair. While a resident bathroom flooded, LPA received no information supporting the allegation that the facility is in disrepair as the issue was promptly and properly addressed.

Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the allegations that staff failed to provide a comfortable environment for residents and facility is in disrepair occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6