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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604389
Report Date: 04/12/2021
Date Signed: 04/12/2021 04:36:29 PM

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 TRI-CITYFACILITY NUMBER:
374604389
ADMINISTRATOR:CELIS, GERALDINA PFACILITY TYPE:
740
ADDRESS:3218 MIRA MESA AVE.TELEPHONE:
(619) 208-7869
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:6CENSUS: 0DATE:
04/12/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Gina Celis, AdministratorTIME COMPLETED:
03:37 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted a Pre-Licensing Virtual Visit, via video conference, due to COVID-19, to observe the facility for compliance with Title 22, Division 6, of California Code of Regulations and Health & Safety Code. The LPA was joined on the video call by Geraldina Celis, Administrator.

The LPA and administrator toured the physical plant, and LPA observed the following: resident accommodations, including furnishings, linens, and personal hygiene items; resident bathrooms were equipped with grab bars, non-skid mats, and water temperature measured at 113.5 and 120 degrees Fahrenheit in two bathrooms designated for use by residents; resident and staff records will be located in a locked cabinet; food service, including dishes, utensils, refrigerators, freezers, and adequate food storage and preparation space are present; cleaning and potentially toxic substances are stored in a locked bin stored in the garage; is locked closet will be used for storage of medication; two first aid kits are stored in a locked closet; sufficient space in which to conduct activities is present; a fire extinguisher is present and mounted in the facility; smoke and carbon monoxide detectors are present, were recently inspected, and determined to be operable by fire safety inspector; required facility postings are present and visible in a common area of the facility. According to the administrator, there are and will be no guns, weapons, or ammunition stored on the facility property. No swimming pool or body of water was observed on the facility property; however, LPA observed a fountain with no water in the front yard of the facility, which the administrator advised is non-functional and will not contain water at any time.

The administrator’s certification for Geraldina Celis expires on July 30, 2021. Component III was conducted and completed following the pre-licensing physical inspection.

Items reviewed during the visit are in compliance with Title 22, Division 6, Chapter 8, of California Code of Regulations. The licensee was advised that the application is pending management final review and approval. A copy of this report and Applicant Rights (LIC 9058) were provided to Geraldina Celis and Hong Hanh Le
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
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 TRI-CITY
FACILITY NUMBER: 374604389
VISIT DATE: 04/12/2021
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Dao, Licensee, via electronic mail. An electronic mail read receipt confirmation was requested to be sent to LPA upon receipt of the documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
LIC809 (FAS) - (06/04)
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