306005792-4-1-2026-22-AS-APAO-DTA3HS-20260418181622

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 04/01/2026
Date Signed: 04/01/2026 11:29:39 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2026 and conducted by Evaluator Samer Haddadin

COMPLAINT CONTROL NUMBER: 22-AS-20260113095313

FACILITY NAME:	BLUE SKY MANOR INC		FACILITY NUMBER:	306005792
ADMINISTRATOR:	GABRIEL AIRAPETIAN		FACILITY TYPE:	740
ADDRESS:	280 N WILSHIRE AVE		TELEPHONE:	(714) 844-2667
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY:	50	CENSUS: 21	DATE:	04/01/2026
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Mayra Jimenez AD Assistance		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility did not provide a total daily diet of sufficient quality to meet the resident's needs.
Facility did not administer medications as prescribed.

INVESTIGATION FINDINGS:

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licensing Program Analyst Samer Haddadin conducted an unannounced site visit to the facility to investigate allegations regarding the "Facility did not administer medications as prescribed" and the "Facility did not provide a total daily diet of sufficient quality to meet the resident’s needs." Upon arrival,Mayra Jimenez AD Assistance greeted the Licensing Program Analyst and granted immediate entry to the premises to begin the investigation.
Regarding the allegation that the "Facility did not administer medications as prescribed," Licensing Program Analyst Haddadin reviewed the admission records for Resident 1, who was admitted to the facility on December 18, 2025. During the course of the investigation, the Licensing Program Analyst interviewed four staff members. Each staff member consistently reported that Resident 1 occasionally refuses to take prescribed medications.
{***CONTINUE 9099C ****}

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260113095313

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/01/2026

NARRATIVE

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They noted that while they explain the importance of medication compliance and the potential health consequences of refusal, they are professionally and legally obligated not to force a resident to take medication against their will. These statements were further supported by an interview with Resident 1 conducted on April 1, 2026, in which they admitted to refusing medication when they do not feel well. Resident 1 also confirmed that staff members consistently attempt to encourage them to remain compliant. Furthermore, an interview with one of four residents corroborated that Resident 1 refuses medication and that staff are seen encouraging them to take it. The remaining three residents interviewed were unable to provide information regarding this specific allegation. Furthermore, during a records review of the Medication Administration Record (MAR) dated March 19th, 25th, 27th, and 28th of 2026, it was shown that Resident 1 refused their medication.
The second allegation concerned whether the "Facility did not provide a total daily diet of sufficient quality to meet the resident’s needs." The Licensing Program Analyst’s review of Resident 1’s records indicated that they were not on a special or restricted diet. During a health and safety walk-through, the Licensing Program Analyst observed the lunch service in progress. The meal being served to all residents consisted of beef empanadas accompanied by mixed fruits and vegetables. This meal was verified against the facility’s current posted menu and was found to be in full compliance with dietary standards.
Based on the information gathered during the investigation, including interviews conducted and documents reviewed, the Department is unable to determine whether the above allegations occurred as reported. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove or disprove that the alleged violations occurred. Therefore, the allegations are deemed unsubstantiated. An exit interview was conducted, and a copy of this report was discussed with and provided to Mayra Jimenez AD Assistance

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026

LIC9099 (FAS) - (06/04)

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