374604656-1-31-2024-08-AS-ARAZ-CQCQZB-20230328123628

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604656
Report Date: 03/28/2023
Date Signed: 01/31/2024 10:55:10 AM

Document Has Been Signed on 01/31/2024 10:55 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	BLUE SKIES OF PENDLETON		FACILITY NUMBER:	374604656
ADMINISTRATOR:	GAMAB, LAURICE		FACILITY TYPE:	740
ADDRESS:	1395 CORTE BOCINA		TELEPHONE:	(619) 208-7869
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY: 6		CENSUS: 0	DATE:	03/28/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Applicant Hanh Le Dao and Applicant’s Representative Jean Paul Reyes		TIME COMPLETED:	12:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Dang Nguyen and Alyssa Ramirez conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to the Applicant’s Representative, Jean Paul Reyes. Applicant Hong Hanh Le Dao also joined today's visit via video teleconference. The facility fire clearance was granted on 02/28/2023 and reflects that the facility was approved for six (6) residents in total, of which two (2) may be non-ambulatory in Bedroom #4 (per the facility sketch), and none may be bedridden. During today’s visit, LPAs, accompanied by the applicant’s representative, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets, sinks, and showers were in working order. The facility’s ambient internal temperature was 69 degrees F. Water temperatures at taps accessible to residents were compliant: Bathroom #1 sink was 118.2 F, Bathroom #2 sink was 118.8 F, and Kitchen sink was 117.2 F. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BLUE SKIES OF PENDLETON	FACILITY NUMBER: 374604656
	VISIT DATE: 03/28/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

The facility has enough linens, hygiene supplies, dining supplies, and perishable and non-perishable food for future resident use. All kitchen appliances were in working order. Refrigerator temperature was 38 F, and freezer temperature was 0 F. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities.

The facility has locked areas for storage of medication and confidential client and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant, no firearms or ammunition are or will be stored at the facility.

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. One (1) fire extinguisher and one (1) first aid kit were present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6 of California Code of Regulations and California Health & Safety Code. The applicant passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit. Applicant Hong Hanh Le Dao was advised that the facility’s application is pending management final review and approval.

An exit interview was conducted with the applicant, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC809 (FAS) - (06/04)

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