374604738-3-12-2025-08-AS-RABA-DEPSX2-20250312141512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604738
Report Date: 03/12/2025
Date Signed: 03/12/2025 02:15:20 PM

Document Has Been Signed on 03/12/2025 02:15 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 VALLEY		FACILITY NUMBER:	374604738
ADMINISTRATOR/ DIRECTOR:	GAMAB, LAURICE		FACILITY TYPE:	740
ADDRESS:	4676 MARBLEHEAD BAY DR.		TELEPHONE:	(619) 208-7869
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY: 6		CENSUS: 4	DATE:	03/12/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Caregiver Caesar Tapit		TIME VISIT/ INSPECTION COMPLETED:	12:30 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 Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to finish the annual inspection from 2/26/2025. 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 Caesar Tapit. The facility is licensed for a maximum capacity of 6 residents, 4 ambulatory and 2 non-ambulatory in bedroom # 5. The facility has a waiver for 6 hospice residents. During today’s visit, the facility had a census of 4 non-ambulatory residents, 1 of which was bedridden. During the Required 1-year visit on 2/26/2025, LPA Borunda cited the facility for the fire clearance violation and the facility has a pending capacity increase to address the fire clearance violation. The Administrator for the facility is Laurice Gamab and their certificate was valid and current. During visits on 2/26/2025 and 3/12/2025, LPA toured the facility and inspected each room of the facility, including resident and staff 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 111.0 and 112.6 degrees Fahrenheit in bathrooms for resident use. The facility’s internal temperature was measured at 78 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Caesar Tapit, 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 37 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. Continued on LIC809-C page…

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

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

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 THE VALLEY	FACILITY NUMBER: 374604738
	VISIT DATE: 03/12/2025

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
26
27
28
29
30
31
32

Staff present at the facility during the time of the inspection had a criminal background clearance and at least one staff had a first aid certificate. 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.

The Administrator will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days.

During the facility tour, LPA did not observe any grab bars in the shower in the common bathroom. Caregiver Tapit stated that staff currently shower residents in the facility's private bathroom due to the private bedroom being empty. LPA advised Caregiver that when the bedroom is occupied, staff could not shower any residents that did not reside in the attached bedroom in the private bathroom. Therefore, the following deficiency was cited for missing grab bars and noted on the attached LIC809-D page.

An exit interview was conducted with Caregiver Caesar Tapit, 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 Borunda
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/12/2025 02:15 PM - It Cannot Be Edited

Created By: Rebecca A Borunda On 03/12/2025 at 01:52 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 THE VALLEY	FACILITY NUMBER: 374604738
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(4)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the shower in the common bathroom did not have a grab bar, which poses a potential safety risk to 4 of 4 residents in care.
	POC Due Date: 03/31/2025
	Plan of Correction
1 2 3 4	Caregiver spoke with the facility's maintenance person to install a grab bar in the common bathroom. Caregiver stated that the Facility Manager will submit photos of the installed grab bar to the Department by POC due date of 3/31/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3