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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005844
Report Date: 04/23/2025
Date Signed: 04/23/2025 03:14:41 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
11/04/2024 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241104140531
FACILITY NAME:BLUE SKIES OF LAGUNA NIGUELFACILITY NUMBER:
306005844
ADMINISTRATOR:RUTH KHAYFACILITY TYPE:
740
ADDRESS:25437 VIA ESTUDIOTELEPHONE:
(949) 503-3553
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 5DATE:
04/23/2025
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Fnu LawrenceTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident in care in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegation listed above. LPA met with staff Fnu Lawrence and explained the reason for the visit. The investigation into the allegation, staff did not seek medical attention for resident in care in a timely manner, revealed the following. It was alleged that Resident 1 (R1) had a pressure injury, and no action was taken by the facility to have R1 treated by a wound care specialist. R1 moved into the facility on September 17, 2024. R1 had a stage 2 pressure injury at the time of move in. Witnesses interviewed verified this information. A review of R1’s records show R1 received wound care on September 17, 2024, November 27, 2024, and January 20, 2025. Witnesses interviewed could not verify if R1 received would care on any other days. R1 could not verify the days they received wound care. The Administrator reported that wound care was provided to R1 weekly, but the facility does not have records to show the days it was provided. The hospice company would not respond to requests for information.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
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-20241104140531
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 SKIES OF LAGUNA NIGUEL
FACILITY NUMBER: 306005844
VISIT DATE: 04/23/2025
NARRATIVE
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The wound care progress notes for R! for November 27, 2024, show the pressure injury was noted to be stage 3. There is no documented evidence to show R1 received wound care after September 17, 2024, and before November 27, 2024. There is no documented evidence to show R1 received wound care for the time period between November 27, 2024, to January 20, 2025. Based on the evidence gathered, the preponderance of evidence standard has been met, therefore the following allegation, staff did not seek medical attention for resident in care in a timely manner, is deemed SUBSTANTIATED. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20241104140531
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 SKIES OF LAGUNA NIGUEL
FACILITY NUMBER: 306005844
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2025
Section Cited
CCR
87465(a)(1)
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The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by...
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Licensee agrees to train all staff on CCR 87465. Licensee agrees to submit a statement of understanding that they have read and understand CCR 87465. Licensee to submit proof of training and statement of understanding to LPA.
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Resident 1 (R1) had a stage 2 pressure injury that progressed to a stage 3 pressure injury and only received wound care on September 17, 2024, November 27, 2024, and January 20, 2025, which poses an immediate health risk to residents 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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3