374604656-2-27-2024-08-AS-RARZ-D2V2Q5-20240227163522

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604656
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:35:30 PM

Document Has Been Signed on 02/27/2024 04:35 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	BLUE SKIES OF PENDLETON		FACILITY NUMBER:	374604656
ADMINISTRATOR:	GAMAB, LAURICE		FACILITY TYPE:	740
ADDRESS:	1395 CORTE BOCINA		TELEPHONE:	(619) 208-7869
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	6	CENSUS: 5	DATE:	02/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Caregiver Jimmy Merino		TIME COMPLETED:	04:40 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 Caregivers Jimmy Merino and Jamela Reyes Magulod. The facility is licensed for a maximum capacity of 6 residents, 2 of which may be non-ambulatory in bedroom #4. The facility has a waiver for 6 hospice residents. During today’s visit, the facility had a census of 5 residents, all of which were non-ambulatory, which puts the facility over the approved capacity for non-ambulatory residents. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Nguyen N Le and their certificate was valid and current. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident rooms, staff rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed near or on the premises. According to Jamela Reyes Magulod, no firearms or weapons are stored 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 106.0 degrees Fahrenheit in a private resident bathroom and 112.3 degrees Fahrenheit in a common bathroom. The facility’s internal temperature was measured at 74 degrees Fahrenheit. LPA observed cleaning and laundry chemicals stored in unlocked cabinets in the laundry room. 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 40 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the clients that are in good repair and sufficient to meet their needs. 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. Continued on LIC809-C page…

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BLUE SKIES OF PENDLETON	FACILITY NUMBER: 374604656
	VISIT DATE: 02/27/2024

NARRATIVE

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LPA reviewed multiple resident and staff records. Review of resident records revealed that all 5 residents are receiving hospice services and LPA observation of resident rooms and record review revealed that 4 of 5 residents, Resident 1 through Resident 4, did not have a doctors order for bed rails. [Caregiver was provided with an LIC811 Confidential Names list to identify R1-R4] Each resident record 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. 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.

The Administrator 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 over-capacity, unlocked chemicals, and postural supports are cited per CA Code of Regulations Title 22 and noted on the attached LIC809-D pages. Additionally, civil penalties are being assessed for over-capacity and are noted on the attached LIC421IM in the amount of $500.

An exit interview was conducted with Licensee Hong Hanh Le Doa via telephone and Caregiver Jamela Reyes Magulod, whose signature below confirms receipt of a copy of this report, the LIC811, the LIC421IM, and the Licensee Appeal Rights (LIC9058 3/22).

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/27/2024 04:35 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BLUE SKIES OF PENDLETON	FACILITY NUMBER: 374604656
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2024

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 as 5 of 5 residents are deemed non-ambulatory, which is more than the current license of 2 non-ambulatory allows. This poses an immediate safety risk to 5 of 5 residents in care.
	POC Due Date: 02/28/2024
	Plan of Correction
1 2 3 4	Licensee stated they are unable to update the fire clearance of the facility, so Licensee will issue eviction notices for 3 residents and submit copies to the Department by POC due date of 2/28/2024.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 as cleaning and laundry chemicals were stored in an unsecured cabinet in the unlocked laundry room. This poses an immediate health and safety risk to 5 of 5 residents in care.
	POC Due Date: 03/12/2024
	Plan of Correction
1 2 3 4	During the visit, LPA observed staff relocate the items to locked storage. The Licensee will conduct in-service training on proper storage of dangerous chemicals and will submit staff sign in sheets to the Department by POC due date of 3/12/2024.

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/27/2024 04:35 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BLUE SKIES OF PENDLETON	FACILITY NUMBER: 374604656
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

87608 Postural Supports (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record… This requirement is not met as evidenced by: 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 as 4 of 5 (R1-R4) residents did not have a written doctor’s order for the use of either half or full bed rails. This poses an potential personal rights risk to 4 of 5 residents in care.
	POC Due Date: 03/12/2024
	Plan of Correction
1 2 3 4	Licensee will obtain written doctors orders for half or full bedrails for R1-R4 and will submit copies of the order to the Department by POC due date of 3/12/2024.

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC809 (FAS) - (06/04)

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