374604304-6-30-2025-08-AS-RABA-DJ5SXH-20250630141557

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604304
Report Date: 06/30/2025
Date Signed: 06/30/2025 02:16:08 PM

Document Has Been Signed on 06/30/2025 02:16 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 OCEANSIDE		FACILITY NUMBER:	374604304
ADMINISTRATOR/ DIRECTOR:	GAMAB, RAFAEL		FACILITY TYPE:	740
ADDRESS:	322 KEYPORT ST.		TELEPHONE:	(760) 547-5605
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	06/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Caregiver Leonor Gaya		TIME VISIT/ INSPECTION COMPLETED:	02:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rebecca Borunda 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. LPA spoke with House Manager Lauren DeLancy via telephone during the visit. The facility is licensed for a maximum capacity of 6 residents, 5 of which may be non-ambulatory. As of 3/14/2024, the facility has a pending fire clearance request to increase the facility's capacity to 6 non-ambulatory residents, 1 of which may be bedridden. The facility also has a pending waiver request for 4 hospice residents. During today’s visit, the facility had a census of 5 non-ambulatory residents. 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. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 107.6 and 107.8 degrees Fahrenheit in common bathrooms. The facility’s internal temperature was measured at 78 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. LPA also observed locked storage for resident medications and resident and staff files. During the review of the locked medication cabinet, LPA observed the daily medications for all 5 residents were stored in a daily pill box. Interviews with staff revealed that the pill boxes only contained medications for that day. Continued on LIC809-C page…

Sabel Martinez	TELEPHONE: (619) -76-2311
Rebecca A Borunda	TELEPHONE: (619) 318-7620
	DATE: 06/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BLUE SKIES OF OCEANSIDE	FACILITY NUMBER: 374604304
	VISIT DATE: 06/30/2025

NARRATIVE

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During the tour of the backyard, LPA did not observe any shaded area for resident use. Staff Gaya stated that there used to be tarps that were hung from the roof and poles that used to provide shade to the backyard but they were removed. LPA observed a minimum of 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 44 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. According to Leonor Gaya, no firearms or weapons are stored on the premises.

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, initial medical assessment, updated annual reappraisal, 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 was away from the facility for approximately one hour between 11:50am and 12:50pm.

The following two deficiencies were cited for medications not stored in their original container and not having a shaded outdoor area and are noted on the attached LIC809-D page.

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: Sabel Martinez	TELEPHONE: (619) -76-2311
LICENSING EVALUATOR NAME: Rebecca A Borunda	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/30/2025 02:16 PM - It Cannot Be Edited

Created By: Rebecca A Borunda On 06/30/2025 at 01:42 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: BLUE SKIES OF OCEANSIDE	FACILITY NUMBER: 374604304
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87219(h)(2)

Planned Activities

(h) The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas that are easily accessible to residents, protected from traffic, and have adequate shady areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the backyard did not have any shady areas for resident use which poses a potential health risk to 5 of 5 residents in care.
	POC Due Date: 07/14/2025
	Plan of Correction
1 2 3 4	Staff stated that she will re-install tarps to provide shade in the backyard of the facility and will submit photo proof to the Department by POC due date of 7/14/2025.

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
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in that 5 of 5 residents's medications were stored in daily pill boxes, which poses a potential health and safety risk to 5 of 5 residents in care.
	POC Due Date: 07/30/2025
	Plan of Correction
1 2 3 4	House Manager will reach out to hospice agencies to provide vendor training on medication administration and storage to staff. House Manager will submit proof of training to the Department by POC due date of 7/30/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (619) -76-2311

	Rebecca A Borunda
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (619) 318-7620

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025

LIC809 (FAS) - (06/04)

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