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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604570
Report Date: 06/25/2024
Date Signed: 06/25/2024 12:01:55 PM

Document Has Been Signed on 06/25/2024 12:01 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:
06/25/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Caregiver Rommel LandromaTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Case Management - Annual Continuation visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Rommel Landroma.

The facility is licensed for a maximum capacity of 6 residents, 2 of which may be non-ambulatory in bedroom #3 and the facility has a waiver for 4 hospice residents. During today’s visit, the facility had a census of 6 residents. The Administrator for the facility is Laurice Gamab and their certificate was valid and current.

During visits on 6/17/2024 and 6/25/2024, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 114.4 degrees Fahrenheit in a common bathroom. The facility’s internal temperature was measured at 68 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Rommel Landroma, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 45 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate.
Continued on LIC809-C page…
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2024
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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BLUE SKIES OF SAN DIEGO COAST
FACILITY NUMBER: 374604570
VISIT DATE: 06/25/2024
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LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

Facility Management will submit copies of the LIC500 Personnel Report, LIC610 Disaster Plan, and current liability insurance to the Department within 15 business days.

No deficiencies were cited on today’s date. An exit interview was conducted with Caregiver Rommel Landroma, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024
LIC809 (FAS) - (06/04)
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