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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604738
Report Date: 02/26/2025
Date Signed: 02/26/2025 12:45:55 PM

Document Has Been Signed on 02/26/2025 12:45 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 THE VALLEYFACILITY NUMBER:
374604738
ADMINISTRATOR/
DIRECTOR:		GAMAB, LAURICEFACILITY TYPE:
740
ADDRESS:4676 MARBLEHEAD BAY DR.TELEPHONE:
(619) 208-7869
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 6DATE:
02/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Caregiver Jemela MagulodTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Borunda 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 Jemela Magulod. LPA spoke with House Manager Lauren DeLancey via telephone.

During today's visit, LPA briefly toured the facility, reviewed facility records, and observed residents in care.
The facility is licensed for a maximum capacity of 6 residents, 4 of which may be ambulatory and 2 of which may be non-ambulatory in bedroom #5. Review of all residents' medical assessment and appraisal records revealed that 5 of 6 residents (R2, R3, R4, R5, and R6) had a diagnosis of major neuro-cognitive disorder and 5 of 6 residents (R1, R2, R3, R5, and R6) required the use of mechanical aid devices to ambulate, such as walkers and wheelchairs. [Caregiver was provided with an LIC811 Confidential Names List to identify residents] Interviews with facility staff revealed that R4 and R5 are bedridden and unable to get out of bed. LPA confirmed residents' use of mechanical aids via interviews with staff. The diagnosis of major neuro-cognitive disorder and the use of mechanical aids to ambulate revealed that R1, R2, R3, and R6 are non-ambulatory and R4 and R5 are bedridden, which is violation of the facility's fire clearance approved on 3/11/2024. The following deficiency for fire clearance is noted on the attached LIC809-D page. Additionally, an immediate civil penalty in the amount of $500 is assessed and noted on the LIC421IM form.

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

An exit interview was conducted with Caregiver Jemela Magulod, whose signature below confirms receipt of a copy of this report, the LIC421IM, LIC811, and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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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Document Has Been Signed on 02/26/2025 12:45 PM - It Cannot Be Edited


Created By: Rebecca A Borunda On 02/26/2025 at 11:25 AM
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 THE VALLEY
FACILITY NUMBER: 374604738

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
87204 Limitations - Capacity and Ambulatory Status (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...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in that 4 of 6 residents are non-ambulatory and 2 of 6 residents are bedridden, while the facility only has an approved fire clearance for 2 non-ambulatory residents. This poses an immediate safety risk to 6 of 6 residents in care.
POC Due Date: 02/27/2025
Plan of Correction
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House Manager will be submitting an updated LIC200 Application and facility sketch requesting an updated fire clearance of 4 non-ambulatory residents and 2 bedridden residents to the Department by POC due date of 2/27/2025.
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 Borunda
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
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