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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604305
Report Date: 01/30/2023
Date Signed: 01/30/2023 12:04:30 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/15/2022 and conducted by Evaluator Chinwe Nwogene
COMPLAINT CONTROL NUMBER: 18-AS-20221215120556
FACILITY NAME:BLUE SKIES OF SAN MARCOSFACILITY NUMBER:
374604305
ADMINISTRATOR:AQUINO, RODELIO D.FACILITY TYPE:
740
ADDRESS:1119 VIA VERA CRUZTELEPHONE:
(760) 736-4099
CITY:SAN MARCOSSTATE: CAZIP CODE:
92078
CAPACITY:6CENSUS: 6DATE:
01/30/2023
UNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Alma Reyes, caregiver TIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Staff did not refund authorized representative the proper amount after residents’ death.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Chinwe Nwogene conducted an unannounced visit to conclude the complaint investigation into the allegation listed above. LPA met Caregiver, Alma Reyes who was informed of the purpose of the visit. During the investigation, Staff and Resident’s Responsible Party (RP) was interviewed, and Resident file was reviewed.
Regarding the allegation “Staff did not refund authorized representative the proper amount after residents’ death”. LPA’s interview with Resident’s Responsible Party (RP) revealed resident paid $4000 for December 2022 rent, resident passed away on 12/4/2022 and resident’s belongings was removed from the facility on 12/6/2022. The interview revealed resident was only reimbursed $2000 for half of the month. LPA interviewed house manager who stated facility bill’s customers based on level of care and not daily rates. LPA interviewed facility accountant who acknowledged resident should receive more refund and will be issuing resident a refund. LPA reviewed resident’s Admission Agreement. Admission Agreement doesn’t show resident’s daily rate or rate for all basic services which the facility is required to provide.
Based on LPA’s interviews and file review the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division & Chapter number 6) are being cited on the attached LIC9099D). An exit interview was conducted, and a copy of this report was reviewed with and provided to Alma Reyes.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
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 2
Control Number 18-AS-20221215120556
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BLUE SKIES OF SAN MARCOS
FACILITY NUMBER: 374604305
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2023
Section Cited
HSC
1569.652(C)
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Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds;

(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.
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Facility Accountant Hieu Phi, stated a additional refund will be issued to resident RP and the proof will be provided to LPA by the POC due date 2/9/2023.
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This requirement is not met based on evidence by interview and record review. The licensee did not comply by not issuing the resident’s RP the proper refund which poses a potential health, safety or personal rights risk to persons in care.
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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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2