306005844-9-8-2020-22-AS-JALE-BTA3JR-20200908181757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005844
Report Date: 09/08/2020
Date Signed: 09/08/2020 06:18:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BLUE SKIES OF LAGUNA NIGUEL		FACILITY NUMBER:	306005844
ADMINISTRATOR:	CELIS, GERALDINA P		FACILITY TYPE:	740
ADDRESS:	25437 VIA ESTUDIO		TELEPHONE:	(949) 326-0311
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY:	6	CENSUS: 5	DATE:	09/08/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Geraldina Celis		TIME COMPLETED:	12:32 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Joseph Alejandre conducted this announced visit for the purposes of conducting a Pre-licensing visit via FaceTime due to Covid-19 precautions. Applicant Geraldina Celis met with LPA and granted entry and gave a tour of the facility. Facility is to operate Residential Facility for the Elderly capacity is for 6 residents of which 5 can be non- ambulatory and 1 bedridden. Application was submitted to CCL on 5/26/2020. LPA and Administrator observed the following: Structure. Facility has 6 bedrooms, 3 bathrooms, single story house with an attached garage that is being used for storage and kept locked. There is a back yard with two separate seating areas for residents. No bodies of water observed. No obstacles or hazards observed in the backyard. Backyard gate is latched and kept unlocked. Facility telephone number is 949-312-272. Bedrooms Residents. The resident bedrooms are spacious and will easily accommodate the resident's furnishings. Lamps & chairs for each resident bedroom inspected. . Bathroom 1 was clean, faucets and toilet were operational. Bathroom 2 has a broken shower head and is in the process of being repaired. The faucet and toilet are working but the shower is not working. LPA observed the shower door has been removed and is next to the toilet. Tiles and supplies for tiling are stacked in the shower. Applicant informed LPA that bathroom 2 is not being used by residents. Linens & Hygiene Supplies. LPA observed linens and hygiene supplies were well stocked for 5 residents. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. seven days nonperishable food supply and two day perishable food supply observed. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed. Smoke detector/carbon monoxide detector tested operational. Appliances. Stove burners observed operational, microwave, washer, and dryer observed. Knives: Locked/stored in the kitchen cabinet. Toxins: observed locked in the garage. Water temperature. Tested 120 Fahrenheit degrees . Medication cabinet is locked. First-Aid Kit & Activity Supplies. observed and available. Resident & Staff Files change of ownership no files reviewed. Fire clearance was approved by Orange County Fire Authority Inspector Ruben Gomez on 8/7/2020. LPA observed the following, bathroom number 2 is under repair and has building materials stored in it. Bathroom 2 must be fully operational and clear of building materials in order for pre-licensing to be completed. Applicant Geraldina Celis stated she understood and would notify LPA, (continued on LIC 809C)

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 SKIES OF LAGUNA NIGUEL	FACILITY NUMBER: 306005844
	VISIT DATE: 09/08/2020

NARRATIVE

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When the bathroom repairs were completed and the facility was ready for the next pre-licensing inspection. Component III waived, applicant has another RCFE facility. LPA informed applicant that the once the bathroom is repaired and the next pre-licensing inspection completed the CAB specialist would complete the application process. Applicant stated she understood. LPA informed applicant inspection report would be emailed to the applicant and must be signed and returned via email, applicant stated she understood, read receipt confirms applicant received report. Pre-Licensing visit ended.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2020

LIC809 (FAS) - (06/04)

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