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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604304
Report Date: 03/22/2024
Date Signed: 03/22/2024 02:47:07 PM


Document Has Been Signed on 03/22/2024 02:47 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
SAN DIEGO RO, 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:
03/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Caregiver Leonora GayaTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced complaint visit to amend a Complaint Investigation Findings report (LIC 9099). LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Leonor Gaya.

During today’s visit, LPA amended a Complaint Investigation Findings Report (LIC 9099), dated 02/28/24, for a complaint filed on 11/15/21. The report findings were changed to UNFOUNDED. The findings were changed to unfounded because the dates of the alleged incidents for the resident mentioned in the complaint, were for dates that the resident lived at sister facility Blue Skies of San Marcos (facility #374604305).

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 3/22).
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana SilveiraTELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
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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