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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005844
Report Date: 10/06/2021
Date Signed: 10/06/2021 03:38:47 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 NIGUELFACILITY NUMBER:
306005844
ADMINISTRATOR:CELIS, GERALDINA PFACILITY TYPE:
740
ADDRESS:25437 VIA ESTUDIOTELEPHONE:
(949) 326-0311
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 3DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:27 PM
MET WITH:Geraldina CelisTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Joseph Alejandre and Jerome Haley made an unannounced visit to conduct the required annual inspection (mitigation). LPAs were greeted and screened by staff, then granted entry. Administrator Geraldina Celis arrived shortly after. LPAs toured the facility. LPAs observed all bedrooms had the required furnishings. All bedrooms were clean and organized. All 3 bathrooms were clean and operational. LPAs inspected the kitchen. The kitchen was clean and organized. LPAs observed 2 day perishable and 7 day non-perishable food on hand. Smoke detectors tested operational. LPAs observed the administrator's certificate expired on 7/30/2021. LPAs toured the garage. LPAs observed extra food and supplies in the garage. LPAs toured the backyard. No bodies of water observed. Both exit gates are operational. No obstacles or hazards observed. All deficiencies are being cited under Title 22 division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
The licensee shal maintain documentation that the administrator has met the certification requirements specified in section 87406, Administrator Certification Requirements or the recertification requirements in section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by: LPA observed that Administrator Geraldina Celis's Administrator Certificate expired on 7/30/21. This poses a potential health and safety risk to residents in care.
Deficient Practice Statement
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Based on observation & record review the licensee did not comply with the section cited above in one out of one administrator certification requirements which poses/posed a potential health and safety or personal risk to persons in care.
POC Due Date: 10/13/2021
Plan of Correction
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Administrator will complete the required hours of training and submit proof of completion to the Agency so their Administrator's certificate can be renewed and a new copy issued by the Agency.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021
LIC809 (FAS) - (06/04)
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