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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604389
Report Date: 10/11/2021
Date Signed: 10/11/2021 05:56:50 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:
10/11/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:59 AM
MET WITH:Caregiver, Emiliano CuevaTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA), Kristina Ryan conducted an unannounced Case Management visit. LPA identified herself and was granted entry into the facility by Emiliano Cueva. LPA Ryan discussed the purpose of the visit with Mr. Cueva.

On September 22, 2021, LPA Ryan issued a deficiency for an individual working in the facility without a criminal background clearance.

During today’s visit, LPA toured the facility, interviewed staff and residents, and reviewed records. LPA verified that Staff 1 (S1) [LIC 811 Confidential Names List was provided] was not working and/or residing in the facility and had not been at the facility since September 22, 2021. No deficiencies were observed at this time.

An exit interview was conducted with Mr. Cueva. The administrator was provided a copy of this report, LIC 811 Confidential Names list, and the Licensee/Appeal Rights (9058 01/16) via e-mail. An electronic read receipt verifies receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina RyanTELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
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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