<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005792
Report Date: 12/31/2024
Date Signed: 12/31/2024 01:51:54 PM

Document Has Been Signed on 12/31/2024 01:51 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:BLUE SKY MANOR INCFACILITY NUMBER:
306005792
ADMINISTRATOR/
DIRECTOR:		SONA HAKOBYANFACILITY TYPE:
740
ADDRESS:280 N WILSHIRE AVETELEPHONE:
(714) 844-2667
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 50CENSUS: 46DATE:
12/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Sona HakobyonTIME VISIT/
INSPECTION COMPLETED:
04:15 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) Samer Haddadin conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry by Admin Sona Hakobyan.


LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following:

Structure: this is a large commercial facility. Facility is a 25-bedroom, 27-bathroom, 1 story building.

Resident Bedrooms: the 7 resident bedrooms inspected are spacious and easily accommodate the residents’ furnishings. Furniture for 7 resident bedrooms inspected including bed, chair, closet space, and ample lighting.

Bathrooms: the bathrooms were clean; faucets and toilets were operational. Water temperature: tested between 120.00 degrees F and 115.5 degrees in the 7 resident bathrooms inspected. Emergency Phone Numbers, Exit Plan & Menu: reviewed.

Food Service: LPA observed facility has one week of non-perishables foods and two days of perishables foods available as required by regulations. The Facility is contracted with Aizen Fire protection which according to record review, the facility had the fire alarm, Carbon Monoxide and Smoke Detectors tested and serviced on May 22nd, 2024. Fire Extinguishers were fully charged with Service tags dated on November 23rd, 2024. During record review LPA observed that Fire drills are being conducted quarterly with last drill on December 12th, 2024.


Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BLUE SKY MANOR INC
FACILITY NUMBER: 306005792
VISIT DATE: 12/31/2024
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
26
27
28
29
30
31
32
 Toxins: observed locked in the housekeeping room. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. LPA reviewed 7 resident files and 5 staff files, and inspected medications for 7 residents; All residents’ and employes’ records are current and up to date.
Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2