435201809-7-27-2024-26-AS-MMOR-D7KUGY-20240727153507

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435201809
Report Date: 07/27/2024
Date Signed: 07/27/2024 03:35:14 PM

Document Has Been Signed on 07/27/2024 03:35 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	BLUE SKY RESIDENTIAL CARE HOME		FACILITY NUMBER:	435201809
ADMINISTRATOR/ DIRECTOR:	SASHI LATA KUMAR		FACILITY TYPE:	735
ADDRESS:	4040 BRIARGLEN DR.		TELEPHONE:	(408) 314-3253
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY: 6		CENSUS: 6	DATE:	07/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:20 PM
MET WITH:	Administrator Sashi Lata Kumar		TIME VISIT/ INSPECTION COMPLETED:	03:40 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) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff (S1), Eperanza Rustia . During the visit, LPA observed 5 residents and 2 staff. LPA explained the purpose of the visit. LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 2 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. While touring the outside of the facility, LPA observed a two sheds in the backyard. (One with a sliding door the other a wooden door.) LPA observed the storage unit with the sliding door as locked and inaccessible to residents in care. LPA observed the wooden storage unit beside it with the door closed. Staff S1 unlocked the shed. LPA observed chemicals inside. S1 then closed the door and locked it. LPA then pulled the door knob and the door unlocked, even though it was locked. Some of the following toxics were observed in the wooden shed; paint thinner, antifreeze, paint, and Roundup. While touring the staff area of the facility, LPA observed the staff door was unlocked. LPA saw the following; inside the staff area; Staff S1's medications and cleaning products such as Quick Shine Floor Luster & Glass Cleaner. S1 confirmed that his/her medications are in the staff room, but only forgot to lock the door. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 114 degrees F in both resident bathrooms. Page 1 Out of 2.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BLUE SKY RESIDENTIAL CARE HOME	FACILITY NUMBER: 435201809
	VISIT DATE: 07/27/2024

NARRATIVE

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Fire extinguisher was serviced in August 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on June 5, 2024.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 2 residents.

Licensing Program Analyst requested an updated copy of the following documents (if applicable) to be sent to LPA by August 2, 2024.
1.LIC 500, Personnel Summary
2.LIC 308, Designation of Administrative Responsibility
3.LIC400, Affidavit Regarding Client/Resident Cash Resources
4. Liability Insurance
5. LIC200, please update (i.e., new phone numbers etc), if necessary.
6. Qualifications of Administrator (Certificate)
7. Please review your facility program for updates (incorporating new laws and/or regulations)
8. Please submit copy of surety bond

Deficiencies are being cited during today's visit. This report was reviewed with Administrator Sashi Lata Kumar and a copy of the signed report was provided. Appeal rights were provided.

Page 2 Out of 2.

End of Report.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/27/2024 03:49 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/27/2024 03:46 PM

Created By: Manuel Monter On 07/27/2024 at 03:20 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BLUE SKY RESIDENTIAL CARE HOME	FACILITY NUMBER: 435201809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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 & interview, the licensee did not comply with the section cited above. LPA observed the wooden storage unit, in the backyard, did still opened even though the door was locked. LPA observed chemicals inside. LPA observed the staff door was unlocked. LPA saw the following; inside the staff area; Staff S1's medications and cleaning products. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2024
	Plan of Correction
1 2 3 4	ADM stated she will send plan of action on how she will ensure Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. ADM stated she will send a written plan of action and send it to LPA by POC date, July 28, 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:

Romeo Manzano

LICENSING EVALUATOR NAME:

Manuel Monter

LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2024

LIC809 (FAS) - (06/04)

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