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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 03/08/2024
Date Signed: 03/08/2024 05:47:18 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
02/22/2024 and conducted by Evaluator Jessica Cho
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240222081433
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: 47DATE:
03/08/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Sona Hakobyan- AdministratorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility is not providing adequate food service.
Residents missed medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced on a subsequent visit to continue the investigation and deliver the findings into the above allegations. LPA met with Administrator (Admin) Sona Hakobyan and stated the purpose of the visit.

On February 23, 2024, LPA initiated the complaint investigation. LPA conducted the tour of the kitchen, observed one meal service at 12:09pm, interviewed five residents and four staff and obtained copies of pertinent documentation which includes: Resident Roster, Personnel Report, Resident Council Meeting Notes, February 18th-24th Menu, staffs' timesheets along with the residents' Face Sheets, Physician's Reports, and Medication Administratration Records (MARs). On today's visit, LPA interviewed three staff obtained additional documentation such as: Resident Roster, Snack Rounds Logs, Menu (highlighting the catering services), List of Diabetic Residents, Vital Signs Sheet, Communication Log, and the MARs for three residents. The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
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-20240222081433
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: 03/08/2024
NARRATIVE
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It is alleged that the facility is not providing adequate food service. On February 23, 2024, at 12:00pm, LPA toured the kitchen and observed the following: There were ample two-day perishables and seven-day non-perishables food items in the refrigerator and pantry as required per regulation. LPA observed the lunch service from 12:09pm to 12:28pm and the facility is following the menu. Residents were having an open-faced turkey sandwich with gravy, mashed potatoes, green beans, and ice cream prepared by Staff #2 (S2). Food was hot, of portion, nutritionally balanced, and served on time. Based on the review of the Resident Council Meeting Notes dated February 7, 2023, it was noted that the residents requested frozen vegetables, easier to spread butter, and wanting more than one serving of juice. In addition, interviews revealed that two out of the five residents expressed concerns that food was cold, lacking variety and in quantity, and the food not being fresh when prepared by Staff #1 (S1). Five out of the five residents indicated that three meals are currently served daily with snacks in between and expressed satisfaction when meals are prepared by S2. Four out of the five staff also corroborated with the allegation when food was prepared by S1.

It is alleged that the residents missed medications. Per review of the MARs for the month of February 2024, LPA observed that two out of the five residents did not receive their medications. Resident #1 (R1) was not administered Vitamin D2 for (2) days and Gabapentin was not administered for (27) days for Resident #2 (R2). Although interviews revealed that five out of the five residents and three out of the four staff did not corroborate with the allegation, the evidence obtained per record review revealed that the medications previously mentioned were not administered for two out of the five residents.

Therefore, based on LPA's observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegations: Facility is not providing adequate food service and Residents missed medications are deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. Two deficiencies are being cited on the attached LIC9099-D.

An exit interview was conducted with Administrator Sona Hakobyan, and a copy of this report including the LIC9099-C, LIC9099-Ds, LIC811s, and the appeal rights were provided via email at the end of the visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20240222081433
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: 03/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
97555(b))8)
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87555 General food Service Requirements (b) The following food service requirements shall apply: (8) All food shall be of good quality.

This requirement was not met as evidenced by:
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Adminstrator stated that they will submit an Acknowlegement of Understanding for the said deficiency to LPA via email by POC due date.
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Based on interviews, facility did not provide adequate food service when food was prepared by S1 which poses a potential 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: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20240222081433
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: 03/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2024
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
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Adminstrator to submit an Acknowledgement of Understanding for the said deficiency to LPA via email by POC due date and to conduct an in-service training covering the medication procedures and protocols including documentation and to provide a copy of the training form with the signatures of the attendees by March 15, 2024.
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Based on observations and review of records, two out of the five residents did not receive one medication as prescribed during the month of February 2024 which poses an immediate Health 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: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4