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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 04/29/2025
Date Signed: 04/29/2025 03:40:02 PM

Unsubstantiated


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
04/23/2025 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20250423095033
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: 42DATE:
04/29/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Sona Hakobyan, Gabriel Airapetian TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff illegally evicted resident in care.
Staff are withholding a resident’s personal belongings.
Unqualified staff are giving insulin injections to residents in care.
Staff are administering a resident’s prescribed insulin to other residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegations listed above. LPA met with Administrator (AD) Gabriel Airapetian and Program Director (PD) Sona Hakobyan and explained the reason for the visit. LPA and the PD toured the facility. LPA interviewed staff and residents. LPA reviewed resident records. The investigation into the allegation, staff illegally evicted resident in care, revealed the following. It was alleged that on or around March 16, 2025 Resident 1 (R1) was told by the PD that they needed to move out of the facility and were no longer welcome at the facility. The PD denied this allegation. 4 out of 4 staff interviewed reported they never witnessed any staff member telling R1 they needed to move out of the facility. The PD reported that on March 16, 2025, staff called around 10:00pm because R1 was disturbing residents. The PD reported they spoke to R1 on the facility phone and informed R1 they needed to comply with house rules because their behavior was disturbing other residents who wanted to sleep. R1 reported that this conversation took place in person because the PD was at the facility. Staff 1 (S1) reported the conversation was on the phone. After the call R1 walked away.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
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-20250423095033
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: 04/29/2025
NARRATIVE
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R1 reported they moved out of the facility and left that night because the PD had evicted them verbally. The PD reported that R1 was never evicted, never given an eviction notice and was never told they had to leave. R1 verified they were never given an eviction notice. R1 reported that they were not forced out and left of their own free will on March 16, but they didn't feel welcome at the facility. Based on the evidence gathered the allegation is deemed unsubstantiated, meaning although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Regarding the allegation, staff are withholding a resident’s personal belongings, the investigation revealed the following. It was alleged that after R1 moved out the facility, facility staff would not let R1 have their belongings. It was reported that on or around April 11 R1 went to the facility to pick up their belongings but staff told R1 they were too busy and could not help them. Staff 2 who was present reported that R1 was given all of their belongings but was upset it was not in boxes. R1 left and only took some of the their belongings. The (PD) reported R1's belongings are in storage and they can come and pick them up anytime from 9:00 am to 5:00 pm. LPA observed numerous items in facility storage. The PD reported and showed the items that are reported to be R1's belongings. Due to conflicting information being reported from R1 and the facility staff the allegation, staff are withholding a resident's personal belongings is deemed unsubstantiated, meaning although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, unqualified staff are giving insulin injections to residents in care, revealed the following. It was alleged that medication technicians (med-techs) were administering injections to residents. LPA interviewed 3 med-techs who reported that they do not administer insulin injections to any residents. LPA interviewed 4 residents who reported they administer their own insulin injections. R1 reported that med-techs administered her insulin injections. Due to conflicting information reported it cannot be determined what transpired. Therefore the allegation is deemed unsubstantiated, meaning although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

The investigation into the allegation, Staff are administering a resident’s prescribed insulin to other residents in care, revealed the following. It was reported that R1's insulin was being administered to other residents. LPA interviewed 3 med-techs who denied the allegation. LPA interviewed 4 residents who reported they receive their own medication and not anyone else's medication. LPA reviewed 4 resident medications, no discrepancies observed.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20250423095033
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: 04/29/2025
NARRATIVE
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Based on the evidence gathered the allegation is deemed unsubstantiated, meaning although the allegations may have happened or are valid, there is not a 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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3