374604304-4-30-2024-08-AS-IESA-D5TQ8E-20240601115636

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604304
Report Date: 04/30/2024
Date Signed: 04/30/2024 04:49:45 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
11/15/2021 and conducted by Evaluator Liliana Silveira

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20211115114750

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: 4	DATE:	04/30/2024
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Caregiver Leonor Gaya		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Lack of care resulting in serious injury.
Staff did not provide incontinence care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced complaint investigation visit to deliver findings. LPA Silveira introduced themselves, met with Caregiver Leonor Gaya and disclosed the purpose of the visit.

The Department’s investigation consisted of observations and interviews. It was alleged that Resident #1 (R1) suffered a fractured vertebrae while in care at Blue Skies of Oceanside in October of 2021. It was also alleged that R1 was left in soiled clothing for extended periods of time during this same timeframe at Blue Skies of Oceanside.

LPA observations from a facility visit conducted on 11/19/21 revealed that R1 did not reside at Blue Skies of Oceanside. An interview with the Administrator on 11/19/21 also revealed that R1 used to reside at Blue Skies of Oceanside, but was transferred to sister facility Blue Skies of San Marcos in October of 2021 to be closer to family. (CONTINUED ON NEXT PAGE, LIC 9099-C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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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Control Number 08-AS-20211115114750

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 OCEANSIDE	FACILITY NUMBER: 374604304
	VISIT DATE: 04/30/2024

NARRATIVE

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Department interviews conducted with staff and outside sources also revealed that during the time of the alleged incidents, which allegedly took place in October of 2021, R1 resided at Blue Skies of San Marcos.

Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained from observations and interviews, we have found that the complaint was unfounded. An unfounded determination means that the allegation was false, could not have happened and/or is without a reasonable basis. The allegations were not pertinent to this licensed facility.

The report was discussed, and an exit interview was conducted with Caregiver Leonor Gaya. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) was provided to Leonor at the conclusion of the visit. The signature below confirms the receipt of these documents.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 767-2311
LICENSING EVALUATOR NAME: Liliana Silveira	TELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC9099 (FAS) - (06/04)

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