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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604570
Report Date: 06/17/2024
Date Signed: 06/17/2024 04:24:37 PM

Document Has Been Signed on 06/17/2024 04:24 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BLUE SKIES OF SAN DIEGO COASTFACILITY NUMBER:
374604570
ADMINISTRATOR/
DIRECTOR:		STREET, ALMINAFACILITY TYPE:
740
ADDRESS:62 AVENIDA DESCANSOTELEPHONE:
(619) 208-7869
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 6DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Caregiver Rommel LandromaTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Rommel Ladroma.

During today's visit, LPA toured the facility, reviewed facility records, and observed residents in care. During the facility tour, the water temperature in a private resident bathroom was measured at 145.9 degrees Fahrenheit. LPA observed facility staff lower the water heater setting during the visit. LPA also observed a bedroom in the garage containing two beds and staff personal items. Caregivers confirmed during visit that the bedroom was designated for staff use. LPA also observed that 5 of 6 residents were non-ambulatory and the facility is only licensed for a total of 2 non-ambulatory residents.

Due to time constraints, the annual inspection could not be completed and a return visit on a subsequent day is needed.

The following deficiencies were cited for hot water, fire clearance, and non-ambulatory capacity and noted on the attached LIC809-D pages. Additionally, a civil penalty in the amount of $500 was assessed for fire clearance and non-ambulatory status and noted on the attached LIC421IM form.

An exit interview was conducted with Caregiver Rommel Ladroma, whose signature below confirms receipt of a copy of this report, LIC421IM, and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
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 3
Document Has Been Signed on 06/17/2024 04:24 PM - It Cannot Be Edited


Created By: Rebecca A Ruiz On 06/17/2024 at 03:01 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BLUE SKIES OF SAN DIEGO COAST
FACILITY NUMBER: 374604570

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the hot water measured at 145.9 degrees in a private resident bathroom, which poses an immediate safety risk to 6 of 6 residents in care.
POC Due Date: 07/01/2024
Plan of Correction
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Caregiver adjusted the water heater during visit. Caregiver will check hot water temperature daily for 7 days and will submit a copy of the temperature log to the Department by POC due date of 7/1/2024.
Type A
Section Cited
CCR
87202(a)
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that 5 of 6 residents are non-ambulatory and the facility's license is approved for 2 non-ambulatory residents. This poses an immediate safety risk to 5 of 6 residents in care.
POC Due Date: 06/18/2024
Plan of Correction
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Caregiver will submit LIC200 and facility sketch requesting an increase in non-ambulatory status by POC due date of 6/18/2024.
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:Jennifer Lott
LICENSING EVALUATOR NAME:Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/17/2024 04:24 PM - It Cannot Be Edited


Created By: Rebecca A Ruiz On 06/17/2024 at 03:05 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BLUE SKIES OF SAN DIEGO COAST
FACILITY NUMBER: 374604570

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that caregivers are living and sleeping in a bedroom located in the garage, which poses an immediate safety risk to 1 of 1 caregivers.
POC Due Date: 06/21/2024
Plan of Correction
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Caregiver will no longer be sleeping in the garage and will take the beds apart and will provide LPA with a photo of deconstructed bed by POC due date of 6/21/2024. Caregiver is already submitting an LIC200 requesting an updated fire clearance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jennifer Lott
LICENSING EVALUATOR NAME:Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024


LIC809 (FAS) - (06/04)
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