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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604656
Report Date: 03/20/2023
Date Signed: 03/20/2023 07:53:37 PM

Document Has Been Signed on 03/20/2023 07:53 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BLUE SKIES OF PENDLETONFACILITY NUMBER:
374604656
ADMINISTRATOR:GAMAB, LAURICEFACILITY TYPE:
740
ADDRESS:1395 CORTE BOCINATELEPHONE:
(619) 208-7869
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 0DATE:
03/20/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
06:25 PM
MET WITH:Applicant's Representatives Hong Hanh Le Dao, Hieu Phi, and Jean Paul ReyesTIME COMPLETED:
08:00 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of California Code of Regulations and Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to the applicant's representatives, Hong Hanh Le Dao, Hieu Phi, and Jean Paul Reyes.

The facility fire clearance was granted on 02-28-2023 and reflects that the facility was approved for 6 residents in total, of which two (2) may be non-ambulatory and none may be bedridden.



During today’s visit, LPA, accompanied by the applicant's representatives, toured the interior and exterior of the facility and inspected each room. There are items which must be corrected for the facility to comply with regulation(s). The applicant did not pass the pre-licensing inspection, and a return visit will be required.

An exit interview was conducted with the applicant's representatives, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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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