306005952-12-7-2023-22-AS-SSAS-CYGRNT-20231213121053

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005952
Report Date: 12/07/2023
Date Signed: 12/07/2023 12:18:25 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/29/2023 and conducted by Evaluator Celine DePerio

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20231129151213

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: 3	DATE:	12/07/2023
		UNANNOUNCED	TIME BEGAN:	08:49 AM
MET WITH:	Assistant Administrator- Carla Ward		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Facility telephone is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility for the complaint received on 11/29/2023 and to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by staff on duty, who notified assistant administrator Carla Ward about visit.

During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed.

It was alleged that facility telephone is in disrepair. During the visit, LPA De Perio observed that the facility phone was operational due to observing that the phone was ringing. LPA conducted a total of 5 interviews with staff and residents, of which all 5 interviews did not corroborate with the allegation by verifying that the facility telephone works, of which 1 resident interview specified "it always rings".

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20231129151213

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/07/2023

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 26 27 28 29 30 31 32	Based on LPA’s interviews which were conducted, review of documents obtained, and observations, this allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with assistant administrator Ward. A copy of this report was provided and explained.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC9099 (FAS) - (06/04)

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