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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604389
Report Date: 09/22/2021
Date Signed: 09/23/2021 05:05:00 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: 6DATE:
09/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Caregiver, JeanPaul ReyesTIME COMPLETED:
07:10 PM
NARRATIVE
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Licensing Program Analyst (LPA), Kristina Ryan, conducted a case management visit to cite for a deficiency observed upon arrival to the facility for a post licensing visit. LPA was granted entry and met with Staff 1 (S1), JeanPaul Reyes. LPA Ryan spoke with Rafael Gamab, Administrator, via telephone, and discussed the purpose of the visit with the administrator.

Upon commencement of a post-licensing visit, LPA Ryan discovered, through interviews, that Staff 2 (S2) [LIC 811 Confidential Names List was provided to identify the staff], who was present and observed working and residing in the facility at the time of the visit, had been working in the facility since on or about 04/2021 without a current criminal background clearance.

Civil Penalties in the amount of $500.00 are being issued on an LIC 421-BG, for allowing a person who is subject to a background check to work in the facility without first obtaining required criminal background clearance.

Deficiency is cited pursuant to Title 22, Division 6, Chapter 8 of the California Code of Regulations and are listed on an LIC 809-D. This report was discussed with Jean Paul Reyes at the conclusion of the visit. Copies of the report, LIC 421-BG, and Licensee Appeal Rights (9058 01/16) were emailed to the administrator following the visit.


SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2021
Section Cited

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Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Sec 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by...
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 Based upon LPA’s observation and interviews, S2 was working in the facility with no proof of current criminal background clearance. This poses an immediate safety risk to 6 of 6 residents in care. A civil penalty in the amount of $500 was assessed for S2 during today’s visit.
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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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2021
LIC809 (FAS) - (06/04)
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