374604304-2-29-2024-08-AS-JLOT-D2X8VT-20240229215139

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604304
Report Date: 02/29/2024
Date Signed: 02/29/2024 02:58:44 PM

Substantiated

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
01/10/2024 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20240110105212

FACILITY NAME:	BLUE SKIES OF OCEANSIDE		FACILITY NUMBER:	374604304
ADMINISTRATOR:	GAMAB, RAFAEL		FACILITY TYPE:	740
ADDRESS:	322 KEYPORT ST.		TELEPHONE:	(619) 208-7869
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	6	CENSUS: 6	DATE:	02/29/2024
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Caregiver Leonor Gaya		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Staff did not allow residents to have visitors

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Leonor Gaya.

During today's visit, LPA observed residents in care and obtained copies of facility records.

The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that staff did not allow residents to have visitors. Interviews and review of recent medical assessment revealed that Resident 1 (R1) had a diagnosis of major cognitive impairment, was confused and disoriented, and was unable to follow directions or make their needs known. [Caregiver was provided with an LIC811 Confidential Names list to identify R1].

Continued on LIC9099-C page...

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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 5

Control Number 08-AS-20240110105212

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BLUE SKIES OF OCEANSIDE	FACILITY NUMBER: 374604304
	VISIT DATE: 02/29/2024

NARRATIVE

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Interviews with residents, staff, and outside sources revealed that due to an outside dispute, facility staff were instructed by outside parties to deny R1 visitation with Outside Party 1 (OP1). Interviews revealed that OP1 was denied visitation with R1 on multiple occasions and that, at the time of when the Department received the complaint, there was no legal order restricting OP1’s ability to visit with R1. Interviews were not able to confirm if R1 had been asked if R1 wanted to see or visit with OP1. Review of a document regarding visitation for R1 revealed that outside parties requested that facility staff restrict visitation to only approved individuals. Interviews did not reveal that staff prevented the visitation of any other residents or outside parties.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with House Manager Lauren deLantis via telephone and Caregiver Leonor Gaya, whose signature below confirms receipt of a copy of this report, LIC811, and the Licensee Appeal Rights (LIC9058 03/22).

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 08-AS-20240110105212

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BLUE SKIES OF OCEANSIDE	FACILITY NUMBER: 374604304
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/08/2024 Section Cited CCR 87468.1(a)(11)	1 2 3 4 5 6 7	87468.1 (a)(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice... This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	The House Manager stated that staff will allow visitation for all residents and staff will receive in-service training and submit copies of the sign in sheet to the Department by POC due date of 3/8/24.
	8 9 10 11 12 13 14	Based on interviews and records review, the Licensee did comply with the section above due to staff restricting OP1 from visiting with R1. This poses a potential personal rights risk to 6 of 6 residents.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
01/10/2024 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20240110105212

FACILITY NAME:	BLUE SKIES OF OCEANSIDE		FACILITY NUMBER:	374604304
ADMINISTRATOR:	GAMAB, RAFAEL		FACILITY TYPE:	740
ADDRESS:	322 KEYPORT ST.		TELEPHONE:	(619) 208-7869
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	6	CENSUS: 6	DATE:	02/29/2024
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Caregiver Leonor Gaya		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Resident was overmedicated

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Leonor Gaya.

The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that resident was overmedicated, specifically Resident 1 (R1). Interviews and review of recent medical assessment revealed that R1 had a diagnosis of major cognitive impairment, was confused and disoriented, and was unable to follow directions or make their needs known. Interviews revealed that in December 2023, R1 sustained a fall resulting in an injury that required surgery.

Continued on LIC9099-C page…

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 08-AS-20240110105212

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BLUE SKIES OF OCEANSIDE	FACILITY NUMBER: 374604304
	VISIT DATE: 02/29/2024

NARRATIVE

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Interviews and records review revealed that after the fall, R1 was prescribed a mediation for pain relief on an as needed basis. Interviews revealed that the pain medication caused R1 to experience drowsiness as a side effect and staff stopped giving R1 that pain medication as a result. Interviews did not reveal any concerns regarding R1’s pain management or overmedication. Interviews with staff and outside parties denied any instances of R1 or any other residents being overmedicated by facility staff.

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with Caregiver Leonor Gaya, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC9099 (FAS) - (06/04)

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