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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604656
Report Date: 01/29/2026
Date Signed: 01/29/2026 02:58:28 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2026 and conducted by Evaluator Rebecca A Borunda
COMPLAINT CONTROL NUMBER: 08-AS-20260122111953
FACILITY NAME:BLUE SKIES OF PENDLETONFACILITY NUMBER:
374604656
ADMINISTRATOR:GAMAB, LAURICEFACILITY TYPE:
740
ADDRESS:1395 CORTE BOCINATELEPHONE:
(442) 266-2060
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:6CENSUS: 4DATE:
01/29/2026
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Caregiver Arlan AcostaTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Staff did not treat resident with dignity
Staff did not provide incontinence care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to open an investigation and deliver findings regarding the above mentioned allegations. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Caregiver Arlan Acosta.

During today’s visit, LPA toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed residents and staff. LPA was away from the facility from approximately 11:50am to 1:05pm. The Department's investigation consisted of interviews with residents, staff, and outside sources, records review, and tour of the facility. It was alleged that staff did not treat resident with dignity, specifically, that staff hit Resident 1 (R1), and that staff did not provide incontinence care.

Continued on LIC9099-C page...
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 08-AS-20260122111953
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 PENDLETON
FACILITY NUMBER: 374604656
VISIT DATE: 01/29/2026
NARRATIVE
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Review of R1's medical assessments and needs and services plans dated 2025 and 2026 revealed that R1 was diagnosed with a major neurocognitive disorder (NCD), resulting in issues with disorientation, hazard awareness, impulse control, and expressions of frustration. Additionally, R1 was incontinent of bowel and bladder and required staff assistance with bathing, grooming, and toileting. R1 was also receiving hospice services for the major NCD diagnosis. Interviews revealed that R1 was often confused and unable to provide specific details regarding dates and times. Interviews with staff and outside sources revealed that in January 2026, R1 reported that an individual entered R1's room and hit them in the face, resulting in bruises. Interviews with staff and outside sources, as well as LPA observation, revealed that the individual R1 described did not fit the description of any staff working at the facility. Additionally, those interviews did not reveal any evidence of the existence of any bruising on R1 since R1's admission to the facility. During today's visit, LPA did not observe any bruising, cuts, or other injuries on R1's face or hands. Additionally, R1 denied that any individual had hit, cursed, or yelled at R1 while living at the facility. An outside source stated that they believed that R1 was extremely confused or experiencing hallucinations when they made the allegation. Interviews with residents, including R1, did not reveal any concerns regarding staff assistance or interactions and residents stated that staff were nice and helpful.

Interviews with staff revealed that all residents at the facility wore incontinence briefs and required staff assistance with toileting, brief changes, showers and bed-bath services. Staff stated that a couple residents were able to let staff know when they required brief changes, and staff would check on residents every two hours for brief changes. Interviews revealed that for residents in bed, staff would place incontinence pads beneath residents to catch any possible leaks from the resident's incontinence brief. Staff denied putting two briefs on any residents, and stated that some residents would be checked and changed more often than every two hours. Additionally, staff stated they provided toileting and brief change assistance to residents multiple times overnight. Interviews with outside sources and residents did not reveal any concerns regarding incontinence care, or any other type of care and supervision provided by facility staff. Those interviews also did not reveal any evidence that any residents had been placed in two briefs.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Caregiver Arlan Acosta, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
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