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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604304
Report Date: 03/14/2024
Date Signed: 03/14/2024 03:55:29 PM


Document Has Been Signed on 03/14/2024 03:55 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



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:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Staff Teresita DiazTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Leonor Gaya.

The facility is licensed for a maximum capacity of 6 residents, 5 of which may be non-ambulatory. The facility has a waiver for 3 hospice residents. During today’s visit, the facility had a census of 6 residents, all of which were non-ambulatory. The facility also had 4 residents receiving hospice services. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Rafael Gamab and their certificate was valid and current.

During today’s visit, LPA toured the facility and inspected each room of the facility, including resident and staff rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 134.4 degrees Fahrenheit in a common bathroom. Caregiver Leonor Gaya turned the water heater down and the water temperature was measured at 118.2 degrees Fahrenheit in the same bathroom. The facility’s internal temperature was measured at 73 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Leonor Gaya, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. LPA observed pillboxes for 6 residents which contained the medication doses for the noon, pm, and bedtime medication passes for all 6 residents. LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 45 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit.

Continued on LIC809-C page…
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/14/2024
NARRATIVE
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LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate.

LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

The Administrator will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days.

The following deficiencies for fire clearance, hospice waivers, medications, and hot water temperature were cited per California Code of Regulations Title 22 and noted on the attached LIC809-D pages. Additionally, a civil penalty for the fire clearance in the amount of $500 is being issued on an LIC421IM.

An exit interview was conducted with House Manager Lauren di Lantis via phone and Caregiver Leonor Gaya, whose signature below confirms receipt of a copy of this report, the LIC421IM, and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/14/2024 03:55 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BLUE SKIES OF OCEANSIDE
FACILITY NUMBER: 374604304

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
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
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Based on record review, the licensee did not comply with the section cited above in that 6 of 6 residents were deemed non-ambulatory, which is over the current fire clearance of 5 non-ambulatory residents, which poses an immediate safety risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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House Manager will submit and LIC200 and facility sketch requesting an increase in non-ambulatory capacity to the Department by POC due date of 3/15/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 03/14/2024 03:55 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BLUE SKIES OF OCEANSIDE
FACILITY NUMBER: 374604304

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in that the water temperature was measured at 134.4 degrees F, which is higher than the required 120 degree F maximum allowed by regulation. This poses a potential safety risk to 6 of 6 persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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During LPA's visit, Caregiver Gaya turned down the water heater and the water was measured within regulation requirements. House Manager stated staff will check and log the hot water temperature in resident bathrooms every other day. The House Manager will send a copy of the hot water log to the Department by POC due date of 3/29/2024.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and interviews, the licensee did not comply with the section cited above in that 6 of 6 residents medications were not stored in their original container and the doses for the next 24 hours were stored in a daily pillbox, which poses a potential health risk to 6 of 6 persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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The House Manager will conduct in-service training for staff on proper medication administration and storage and staff will use a MAR to record medication doses. The House Manager will send a copy of the in-service sign in sheet to the Department by POC due date of 3/29/2024.
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 TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 03/14/2024 03:55 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: BLUE SKIES OF OCEANSIDE
FACILITY NUMBER: 374604304

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632(a)(1)
(a) In order accept or retain terminally ill residents... the licensee shall have obtained a facility hospice care waiver from the Department. ... The request shall include, but not be limited to the following:

(1) Specification of the maximum number of terminally ill residents which the facility wants to have at any one time.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the facility has a current hospice waiver for 3 residents and that 4 of 6 residents are currently receiving hospice services, which poses a potential health risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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The House Manager will submit an hospice waiver increase to at least 4 residents to the Department by POC due date of 3/29/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5