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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604765
Report Date: 07/24/2025
Date Signed: 07/24/2025 02:44:37 PM

Document Has Been Signed on 07/24/2025 02:44 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 HILLFACILITY NUMBER:
374604765
ADMINISTRATOR/
DIRECTOR:		GAMAB, RAFAEL AFACILITY TYPE:
740
ADDRESS:4875 MARBLEHEAD BAY DRTELEPHONE:
(657) 203-4905
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 6CENSUS: 5DATE:
07/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Caregiver Rina CanonizadoTIME VISIT/
INSPECTION COMPLETED:
02:45 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 Rina Canonizado. LPA spoke with House Manager Lauren DeLancey via telephone during the visit.

The facility is licensed for a maximum capacity of 6 residents, 2 of which may be non-ambulatory in bedroom #1. The facility has a waiver for 6 hospice residents. During today’s visit, the facility had a census of 5 residents, all of which were non-ambulatory and receiving hospice services. The Administrator for the facility is Rafael Gamab and their certificate was valid and current.
During today’s visit, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. Upon attempting to enter the facility, LPA observed a locked gate with a keypad preventing access to the front door. Staff Canonizado exited the facility and entered a code into the keypad which unlocked the gate and allowed LPA entrance into the facility. The facility's approved fire clearance granted on 3/15/2024 did not note any use of locked perimeter or delayed egress. LPA tested the gate during the facility tour and observed that the gate was locked from both sides, preventing unobstructed egress in case of emergency. Additionally, a tour of the facility's backyard revealed that the side gate was locked at the time of the inspection and had a doorknob with a locking mechanism, further preventing egress is case of emergency. The facility was found to be clean, safe, and in good repair. The facility’s water temperature was measured at 107.2 degrees Fahrenheit at the kitchen sink and 117.0 degrees Fahrenheit in a common bathroom. The facility’s internal temperature was measured at 73 degrees Fahrenheit.
Continued on LIC809-C page...
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Rebecca A Borunda
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BLUE SKIES OF THE HILL
FACILITY NUMBER: 374604765
VISIT DATE: 07/24/2025
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LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Rina Canonizado, 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. According to staff and LPA observation, the facility refrigerator located in the kitchen was non-operational and was empty of food supplies. The facility has a refrigerator and freezer located in the garage that was operational and contained the perishable food supply. The garage refrigerator and freezer temperatures were kept within regulatory levels. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs.

Staff present at the facility during the time of the inspection had a criminal background clearance and had a first aid certificate. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, initial medical assessment, updated annual reappraisal, documents regarding safeguarding personal property and personal rights. Review of resident records revealed that 5 of 5 residents were deemed non-ambulatory due to either the diagnosis of a major neuro-cognitive disease or the use of ambulation devices such as walkers and wheelchairs. Additionally, review of hospice binders revealed that 3 of 5 residents (Residents 1, 2, and 4) did not have hospice care plans. [Staff Canonizado was provided with an LIC811 Confidential Names list to identify residents.] Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance, and a health screening. LPA was away from the facility for approximately one hour between 11:10am and 12:10pm.

The following deficiencies were cited for locked perimeter gates, over capacity for non-ambulatory residents, and missing hospice care plans and noted on the attached LIC809-D pages. Additionally, two civil penalties in the amount of $500 each, totalling $1,000 were assessed for locked perimeter and non-ambulatory capacity and noted on the attached LIC421IM forms. Additionally, LIC9102TV Technical Violations regarding staff association and shaded outdoor spaces were provided.

An exit interview was conducted with House Manager Lauren DeLancey via telephone and Caregiver Rina Canonizado, whose signature below confirms receipt of a copy of this report, the LIC421IMs, the LIC811, the LIC9102TV forms, and the Licensee Appeal Rights (LIC9058 3/22).
NAME OF LICENSING PROGRAM MANAGER: Sabel Martinez
NAME OF LICENSING PROGRAM ANALYST: Rebecca A Borunda
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/24/2025 02:44 PM - It Cannot Be Edited


Created By: Rebecca A Borunda On 07/24/2025 at 01:28 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 HILL
FACILITY NUMBER: 374604765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
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. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 5 of 5 residents are non-ambulatory due to using ambulatory devices or diagnosis of major neuro-cognitive disease which poses an immediate safety risk to 5 of 5 residents in care.
POC Due Date: 07/25/2025
Plan of Correction
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House Manager will review facility paperwork to determine if a capacity change request has already been submitted to the Department and will either submit a copy of pending capacity change paperwork or will submit a new LIC200 and facility sketch requesting an increase is non-ambulatory clearance to the Department by POC due date of 7/25/2025.
Type A
Section Cited
CCR
87705(f)
Care of Persons with Dementia
(f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that the front and side gates are locked without fire clearance approval, which poses an immediate health and safety risk to 5 of 5 residents in care.
POC Due Date: 07/28/2025
Plan of Correction
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House Manager called repair person to remove the locking mechanisms on both gates on 7/26/2025. House Manager will provide the Department proof of scheduling by 7/25/2025 and will submit photographs of the gates without locks to the Department by POC due date of 7/28/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Rebecca A Borunda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2025 02:44 PM - It Cannot Be Edited


Created By: Rebecca A Borunda On 07/24/2025 at 01:28 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 HILL
FACILITY NUMBER: 374604765

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 3 of 5 residents (R1, R2, and R4) did not have hospice care plans in their records which poses a potential health risk to 3 of 5 residents in care.
POC Due Date: 08/01/2025
Plan of Correction
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House Manager stated that she will obtain hospice care plans for R1, R2, and R4 from their hospice providers and will send copies of the care plans to the Department by POC due date of 8/1/2025.
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.
Sabel Martinez
NAME OF LICENSING PROGRAM MANAGER:
Rebecca A Borunda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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