306005952-10-13-2022-22-AS-JCHO-CK6TBL-20221013143519

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005952
Report Date: 10/13/2022
Date Signed: 10/13/2022 02:35:46 PM

Document Has Been Signed on 10/13/2022 02:35 PM - It Cannot Be Edited

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 HILLS		FACILITY NUMBER:	306005952
ADMINISTRATOR:	GAMAB, RAFAEL ABRENICA		FACILITY TYPE:	740
ADDRESS:	25811 TREE TOP RD.		TELEPHONE:	(619) 208-7869
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	6	CENSUS: 6	DATE:	10/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Emilia Mendoza		TIME COMPLETED:	02:50 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	On 10/13/2022 at 10:01am, Licensing Program Analyst (LPA) Jessica Cho arrived at Blue Skies of Laguna Hills to conduct an unannounced visit. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on Infection Control. At 10:09am, LPA Cho was greeted by Caregiver Leopaldo Mendoza followed by Emilia Matias Mendoza. LPA entered the facility and completed the Coronavirus 2019 (COVID-19) screening after the thermometer was repaired. LPA observed a sign in sheet documenting temperatures of visitors. Per Caregiver Emilia, the facility does not document daily temperatures of staff and residents. Caregiver Emilia was advised on documenting temperatures. At 10:15am, LPA spoke to Administrator (Admin) Laurice Gamab via a telephone call and stated the purpose of the visit. LPA Cho discussed with Admin that Staff #1 (S1) to Staff #4 (S4) were not associated to this facility per the LIS Personnel Summary Report and Guardian. It was determined via Guardian that S1 to S4 were fingerprint cleared and associated to other facilities operated by the licensee. It was determined that S4 was previously associated to this facility but was separated on 05/01/2022 per Guardian notes. Additionally, Admin confirmed that Admin did not have access to Guardian therefore S1 to S4 were not associated during the visit. Admin stated that the facility manager will be informed of the association status for the four staff. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The Complaint Poster (PUB475) did not meet the size requirement. The facility is licensed for six non-ambulatory residents and has a hospice waiver for three. There are currently six residents living in the facility of which four are in hospice care. Facility is operating beyond the maximum number of persons who may receive hospices services at one time.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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 HILLS	FACILITY NUMBER: 306005952
	VISIT DATE: 10/13/2022

NARRATIVE

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At 10:48am, LPA Cho conducted a tour of the physical plant along with Caregiver Emilia Mendoza. The single story home consists of five resident bedrooms and three resident bathrooms. There is one staff private bedroom. The staff bedroom did not have a locking mechanism and had two unsecured bottles of supplements on the night stand. The facility also has a living room, dining area, kitchen, and an attached two-car garage with laundry. The resident bedrooms were checked. Resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. The resident bathrooms were checked. The toilets worked properly, grab bars were secure, the showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels, personal hygiene, and incontinence supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperature and the water temperatures measured at 120.2 degrees Fahrenheit in the Bathroom #1, 121.2 degrees Fahrenheit in Bathroom #2, and 119.8 degrees Fahrenheit in Bathroom #3. LPA Cho inspected the kitchen. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was mounted, fully charged, but the service date was unknown. Admin Laurice also confirmed this information on a telephone conversation at 11:27am. The smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications and toxins were unsecured and accessible to the residents. LPA observed unsecured medications and toxins in the following areas: staff bedroom had two bottles of supplements on the night stand, two bottles of detergents in the unlocked garage, and cleaning solutions were unsecured under the sink cabinet. The two bottles of supplements were removed from the staff bedroom, the key pad to the garage was in the process of being repaired during the visit, and the left cabinet under the sink was repaired during the visit. LPA Cho toured the outside grounds. No bodies of water was present, and there was shading and sufficient seating for residents in the backyard. Walkways around the home were clear of hazards, and there were no security bars or weapons on the premises. The exit side gates were self-closing and self-latching. Facility was unable to provide the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Admin confirmed the LIC610E was unavailable. Facility will complete and submit the LIC610E form per the Provider Information Notice (PIN 22-02-ASC) released on 01/06/2022. LPA observed sufficient supply of emergency food/water and PPEs. The first aid kit met all the required components except a first aid manual.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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 HILLS	FACILITY NUMBER: 306005952
	VISIT DATE: 10/13/2022

NARRATIVE

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At: 11:24am, LPA provided the following guidance to Administrator Laurice Gamab via a telephone call: to document residents and staff temperatures daily, to enlarge and post the Complaint Poster (PUB475), to service/obtain a fire extinguisher annually, to obtain a current edition of the first aid manual, to complete and submit the Emergency and Disaster Plan (LIC610E), to ensure all employed staff are associated, to update the roster on Guardian, to ensure facility accepts and serves residents within the approved hospice capacity, and to ensure all medications and toxins are secured at all times. In addition, Admin was also reminded the importance of staying abreast with CCLD’s COVID-19 guidance and additional information by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov. At 3:03pm, Administrator Laurice Gamab confirmed via text designating Caregiver Emilia Mendoza to sign the report on behalf of the Admin.

Based on the observations made during today's visit, deficiencies are cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102s) were issued during the visit. An exit interview was conducted with Caregiver Emilia Mendoza, and a copy of this report (LIC809, LIC809Cs, LIC809Ds, LIC9102s, LIC811s along with the appeal rights) were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/13/2022 02:35 PM - It Cannot Be Edited

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 HILLS	FACILITY NUMBER: 306005952
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews, and record review, the facility did not ensure four of four staff were not associated to the facility as required prior to employment which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	Licensee acknowledges and agrees to associate S1 to S4 and to forward proof of correction by POC due date to LPA Cho.

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, staff supplements, resident medications, and cleaning solutions/toxins were unsecured which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	The medication cabinet was immediately locked and the sink cabinet was repaired during the visit. Licensee to provide proof of installation/repair of a locking mechanism to the staff bedroom and garage door, and staff training to LPA Cho via email by POC due date.

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

Page: 9 of 10

Document Has Been Signed on 10/13/2022 02:35 PM - It Cannot Be Edited

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 HILLS	FACILITY NUMBER: 306005952
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87204(a)

87204 Limitations- Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, and interviews of Administrator and care staff, the facility is operating beyond the maximum number of persons who may receive hospice servies at one time. Facility has an approved hospice waiver for three but four hospice residents were noted at this time which poses a potential Health, Safety, and Personal Rights risk to persons in care.
	POC Due Date: 10/20/2022
	Plan of Correction
1 2 3 4	Licensee agrees to submit an increase of hospice waiver request and to forward proof to LPAs Ruth Martinez and Jessica Cho by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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