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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881527
Report Date: 02/09/2024
Date Signed: 02/09/2024 12:35:56 PM


Document Has Been Signed on 02/09/2024 12:35 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:BLUE SKIES LUXURY SENIOR RESORTFACILITY NUMBER:
331881527
ADMINISTRATOR:GAMAB, LAURICEFACILITY TYPE:
740
ADDRESS:38355 VISTA DEL BOSQETELEPHONE:
(657) 203-4905
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:5CENSUS: 0DATE:
02/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Applicant: Yann CoudronniereTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an announced visit to the home in order to conduct an initial pre-licensing inspection. LPA met with Applicant, Yann Coudronniere, and Administrator, Laurice Gamab.

LPA conducted a walk through and reviewed the pre-licensing documents. The facility will serve elderly ages 60 and above in a residential care facility for the elderly. The fire clearance was approved for (5) ambulatory residents of which (2) may be non-ambulatory.

The home is a one story home with attached garage, with (4) bedrooms and (4) bathrooms, and (1) shower room. There is a pool surrounded by a locked gate in the backyard. No firearms are present at the facility. LPA observed PPE equipment and hand washing stations in the facility. LPA observed the emergency supplies and emergency exits. The physical plant was observed to be in good repair and free of hazards. Provisions of safety will be installed with grab bars in resident bedrooms. Applicant agreed to send LPA proof by Monday 2/16/2024 Close of Business (COB). The bedrooms had the required furniture, extra linens will be purchased by the applicant, proof is due by 12/16/2024 COB. The facility kitchen can prepare food in a clean and safe environment. The facility possessed requirement amount of food supplies. The smoke and carbon monoxide alarms were tested and observed to be operational. There are designated locked areas for resident medication and sharp hazardous objects. The hot water temperature was recorded in resident restroom at 112F, and the land line was operational at... The applicant showed the LPA a list of activities to be conducted and stated they would purchase these items and show proof to LPA by 12/16/2024 COB. Night lights will also be purchased to place in facility hallways, due by 12/16/2024 COB. The laundering equipment is expected to arrive 12/16/2024, proof of this is due by 12/16/2024 COB.

The above corrections will need to be provided by the agreed upon dates in order for the applicant to proceed in the pre-licensing process. An exit interview was conducted with Applicant, Yann Coudronniere, and Administrator, Laurice Gamab, where this report ad provided to them.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
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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