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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604570
Report Date: 08/16/2022
Date Signed: 08/16/2022 11:08:10 AM

Document Has Been Signed on 08/16/2022 11:08 AM - 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 SAN DIEGO COASTFACILITY NUMBER:
374604570
ADMINISTRATOR:STREET, ALMINAFACILITY TYPE:
740
ADDRESS:62 AVENIDA DESCANSOTELEPHONE:
(619) 208-7869
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 0DATE:
08/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:House Operation Manager, Lauren DelanceyTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Sabel Martinez, conducted a scheduled Pre-licensing inspection to observe the physical plant for compliance and conduct a Component III. The fire inspection was completed on 5/6/2022 and the facility is approved for 4 ambulatory residents and 2 non-ambulatory residents in bedroom #3. The facility has an approved hospice waiver for 4 residents.

The LPA was greeted by Applicant, Lauren Delancy. The LPA was granted entry after identifying himself and disclosing the purpose of the visit. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand washing stations readily available; a designated visitation area; and emergency agencies’ contact information posted in a location visible to staff and residents..

Additionally, the LPA observed exterior and interior passageways were free from obstructions. All of the residents’ rooms were equipped with the required furnishings. Bathrooms were observed to be sanitary and operational with grab bars and skid mats. A functioning carbon monoxide detector and smoke detectors were observed in the facility. No bodies of water were observed. The facility was stocked with a 2 day supply of perishable and a 7 day supply of nonperishable food items. Cleaning supplies were observed to be locked and inaccessible to residents. Per the House Operation Manager, there are no firearms at the facility. The LPA completed the Component III where continuing operation requirements, record keeping, reporting requirement and physical plant compliance were discussed.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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 SAN DIEGO COAST
FACILITY NUMBER: 374604570
VISIT DATE: 08/16/2022
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The Pre-licensing and Component III were completed on today's date. The facility is ready to be licensed pending management approval. This is an initial application and there no residents in care at this time. An exit interview was conducted with House Operation Manager, Lauren Delancey, to whom a copy of this report along with Applicant/Appeal Rights (LIC9058 01/16) were provided to.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC809 (FAS) - (06/04)
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