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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604765
Report Date: 04/04/2024
Date Signed: 04/04/2024 11:50:11 AM

Document Has Been Signed on 04/04/2024 11:50 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BLUE SKIES OF THE HILLFACILITY NUMBER:
374604765
ADMINISTRATOR:GAMAB, RAFAEL AFACILITY TYPE:
740
ADDRESS:4875 MARBLEHEAD BAY DRTELEPHONE:
(657) 203-4905
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 0DATE:
04/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Applicant Yann CoudronniereTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an announced Pre-Licensing visit. LPA was met by Applicants Yann Coudronniere, HongHanh Le Dao, and Lauren DeLancey and was granted entry into the facility. The purpose of today's visit is to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. The fire inspection was completed on 3/15/2024 and the facility is approved for a total of 6 residents, 4 of which may be ambulatory and 2 of which may be non-ambulatory in bedroom #1.

During today's visit, LPA toured the facility and inspected every room. The facility was found to be clean and in good repair with no pathway obstructions. Resident bathrooms were observed to be clean and the toilets and showers were found to be in working order. The facility's water temperature in a common bathroom was measured at 108.0 degrees Fahrenheit and in a private bathroom was measured at 112.7 degrees Fahrenheit. LPA observed locked storage areas where all hazardous and/or toxic chemicals were stored and secured. LPA observed locked storage for resident' medications. Fire extinguishers were observed throughout the facility and found to be in compliance. A functioning carbon monoxide detector and smoke detectors were observed in the facility. No bodies of water were observed near or on the premises. LPA observed 7-day supply of non-perishable food. Required postings were observed in the entrance to the facility.

LPA conducted Component III with the applicant.s The topics discussed were continuing operation requirements, record keeping/reporting, and physical plant compliance. LPA reviewed the applicant's Infection Control plan and Emergency Disaster plan.

Pre-licensing is complete, and this facility has no deficiencies. It is recommended that this facility be licensed pending final review and approval. An exit interview was conducted with the applicants, 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: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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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