374604389-5-9-2024-08-AS-RARZ-D54TL6-20240509144900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604389
Report Date: 05/09/2024
Date Signed: 05/09/2024 02:49:09 PM

Document Has Been Signed on 05/09/2024 02:49 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 TRI-CITY		FACILITY NUMBER:	374604389
ADMINISTRATOR:	RAFAEL GAMAB		FACILITY TYPE:	740
ADDRESS:	3218 MIRA MESA AVE.		TELEPHONE:	(619) 208-7869
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92056
CAPACITY:	6	CENSUS: 5	DATE:	05/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Caregiver Eden Chavez		TIME COMPLETED:	03:00 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 Ruiz 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 Eden Chavez. LPA spoke with House Manager Lauren De Lantis via telephone during the visit. The facility is licensed for a maximum capacity of 6 residents, 4 may be non-ambulatory. The facility has a waiver for 3 hospice residents. During today’s visit, the facility had a census of 5 residents, all of which were non-ambulatory, which is a violation of the facility's fire clearance. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Rafael Gamab and their certificate expired on 4/26/2024. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 142.2 degrees Fahrenheit in a common bathroom, which is above regulation requirements. During the visit, LPA observed staff lower the facility water heater setting. The facility’s internal temperature was measured at 73 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Ann Sulangi, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and label. LPA observed 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 37 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. Continued on LIC809-C page…

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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

FACILITY NAME: BLUE SKIES OF TRI-CITY	FACILITY NUMBER: 374604389
	VISIT DATE: 05/09/2024

NARRATIVE

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LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, 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. 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 spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns. LPA was away from the facility for approximately one hour between 12:00pm and 1:00pm.

The House Manager will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days.

The following deficiencies for fire clearance, Administrator Certificate, and hot water temperature were cited and noted on the attached LIC809-D pages. A civil penalty for a fire clearance violation totalling $500 was issued and noted on the attached LIC421IM form. Additionally, a technical violation regarding hospice waivers was issued and noted on an LIC9102TV form.

An exit interview was conducted with House Manager Lauren di Lantis via phone and Caregiver Ann Sulangi in person, whose signature below confirms receipt of a copy of this report, LIC421IM, LIC9102TV, and the Licensee Appeal Rights (LIC9058 3/22).

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/09/2024 02:49 PM - It Cannot Be Edited

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 TRI-CITY	FACILITY NUMBER: 374604389
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87204(a)

Limitations -Capacity and Ambulatory Status

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in that 5 of 5 residents are non-ambulatory and the facility is only approved for 4 non-ambulatory residents which poses an immediate safety risk to 5 of 5 persons in care.
	POC Due Date: 05/10/2024
	Plan of Correction
1 2 3 4	House Manager will submit a written request, LIC200 Application, and facility sketch to increase the facility's non-ambulatory fire clearance to the Department by POC due date of 5/10/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/09/2024 02:49 PM - It Cannot Be Edited

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 TRI-CITY	FACILITY NUMBER: 374604389
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 water temperature measured at 142.2 degrees Fahrenheit which poses a potential safety risk to 5 of 5 persons in care.
	POC Due Date: 05/24/2024
	Plan of Correction
1 2 3 4	LPA observed facility staff turn down the water heater during the visit. House Manager will have their handy man come out to adjust the water temperature and staff will log the water temperature in common bathrooms for 7 days and submit a copy of the water temperature log to the Department by POC due date of 5/24/2024.

Type B

Section Cited

CCR

87405(a)

87406 (a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in that the Administrator Certificate for Rafael Gamab had expired, and the Department did not have proof of a pending recertification application which poses a potential personal rights risk to 5 of 5 persons in care.
	POC Due Date: 06/07/2024
	Plan of Correction
1 2 3 4	House Manager will ensure that Administrator Rafael Gamab submits a recertification application to the Department and will provide the Department with a copy of proof of pending application by POC due date of 6/7/2024. House Manager will have another Administrator cover the facility until the POC is completed.

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: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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