374604765-5-23-2025-08-AS-RCLK-DHLW4E-20250613165722

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604765
Report Date: 05/23/2025
Date Signed: 05/23/2025 10:13:02 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/22/2025 and conducted by Evaluator Rebecca A Borunda

COMPLAINT CONTROL NUMBER: 08-AS-20250522161505

FACILITY NAME:	BLUE SKIES OF THE HILL		FACILITY NUMBER:	374604765
ADMINISTRATOR:	GAMAB, RAFAEL A		FACILITY TYPE:	740
ADDRESS:	4875 MARBLEHEAD BAY DR		TELEPHONE:	(657) 203-4905
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	6	CENSUS: 4	DATE:	05/23/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Caregiver Rina Canonizabo		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Lack of Supervision, resulting in hospitalization

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to open and deliver findings for an investigation regarding the above-mentioned allegation. LPA identified herself to, was greeted by, and explained the purpose of the visit to Caregiver Rina Canonizabo. House Manager Lauren Delancey arrvied during the visit.

During today's visit, LPA toured the facility, conducted a health and safety check, observed residents in care, reviewed resident records, and spoke with facility staff. Interviews with staff revealed that the subject of the complaint did not reside at the facility, which was supported by resident records.

Therefore, it was determined that the complaint allegation is Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted with House Manager Lauren Delancey, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).

Unfounded

Estimated Days of Completion: 0

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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