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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604304
Report Date: 10/20/2022
Date Signed: 10/20/2022 03:39:53 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2022 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20221011075637
FACILITY NAME:BLUE SKIES OF OCEANSIDEFACILITY NUMBER:
374604304
ADMINISTRATOR:GAMAB, RAFAELFACILITY TYPE:
740
ADDRESS:322 KEYPORT ST.TELEPHONE:
(619) 208-7869
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 6DATE:
10/20/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Caregiver, Christine TeloTIME COMPLETED:
03:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not treat resident with dignity
Facility staff forced resident to take medications
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced visit to initiate a complaint investigation regarding the above allegations. The LPA was greeted by Caregiver, Christine Telo, identified himself, and disclosed the purpose of the visit.

During the visit, the LPA conducted a tour of the facility, reviewed pertinent records and interviewed staff. Based upon a review of records and interviews conducted, it was determined Resident # 1 (R1) had not resided at the facility, thus, finding the complaint allegations to be unfounded. This means the allegations were false, could not have happened, and/or were without a reasonable basis. The facility is in compliance with Title 22 regulations at this time, and no deficiencies were cited on today's date

An exit interview was conducted with Caregiver, Christine Telo. A copy of this report and Licensee Rights (LIC 9058) were provided to the Administrator, Rafael Gamab, via electronic mail. An electronic mail read receipt confirms the documents were received by the administrator.
Unfounded
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
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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