BLUE SKY MANOR INC

Official classification

Type A

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

87224 (a)Eviction Procedures - The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty days written notice to the resident is required...This requirement was not met as evidenced by: Based on interview confirmation, Resident (1) was not allowed to come back to the facility after being sent to the hospital on July 29, 2026. R1 was discharged from the hospital the same day July 29, 2026. R1 was not allowed to return to the facility.

Official plan of correction

Administrator Airapetian will read and review the regulation section on Eviction Procedures and send a signed statement of acknowledgment and understanding to LPA Haley by 4:00pm on the POC due date (8.5).

Deadline recorded: Aug 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87213

Regulation authority

CCR

What the official deficiency says

87213 The licensee shall have a financial plan that conforms to the requirements of Section 87155 that assures sufficient resources to meet operating costs for care of residents; may be required upon the written request of the licensing agency. The balance sheet and Profit and Loss Report revealed that the facility lacks sufficient operating funds and cash reserves, has paid utility bills late, and is operating at a net loss, which poses an immediate risk to residents in care.

Official plan of correction

Licensee will have a financial plan drawn by E mailed to LPA by POC due date

Deadline recorded: Apr 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87205(a)

Regulation authority

CCR

What the official deficiency says

Accountability of Licensee Governing Body 87205 (a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility… This requirement was not met as evidence by licensee did not exercise general supervision over the financial affairs of the facility in a manner consistent with the facility’s operation and the welfare of residents in care, as required by Section 87205(a), Accountability of Licensee Governing Body which poses a potential Health, Safety, and/or Personal Rights risk to persons in care.

Official plan of correction

Licensee will have a financial plan drawn by E mailed to LPA by POC due date

Deadline recorded: May 18, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

87208 Plan of Operation (a) " The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so... " This requirement was not met as evidenced by: Based on interviews and record review, the facility is/did not comply with the section cited above by not adhering to the plan of operation approved by Department which poses a potential Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Licensee stated that they will seize accepting residents from the health insurance program, to not evict those residents, and to submit a request in writing in a change of operation to serve different types of residents via email to LPAs Cho and Haddadin by POC due date.

Deadline recorded: May 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on observation, interview, and record review, facility did not maintain complete records in three out of three residents which poses a potential Personal Rights risk to persons in care.

Official plan of correction

Administrator stated that all CCL required forms will be completed and maintained for all STPHH and Recuperative Care residents moving forward and will either also complete missing forms for current residents OR close the program per the licensee's decision by POC due date.

Deadline recorded: Mar 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures (a)-(i) This requirement was not met as evidenced by: Based on the interviews and record review, facility did not issue valid eviction notices to STPHH residents which poses a potential Health, Safety, and/or Personal Rights risk to persons in care.

Official plan of correction

Administrator stated that they will provide a copy of 87224 and a written notice to all current STPHH residents rescinding the initial notice issued on or around 1/24/25 and a meeting will be conducted with all residents discussing the eviction procedures and will obtain signatures from residents attending the meeting. A copy of the attendance sheet will be emailed to LPA by POC due date.

Deadline recorded: Mar 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights … (a) … (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure a resident was accorded dignity when S1 attempted to put a banana into a resident’s mouth against their will when they were having respiratory issues, which poses an immediate personal rights risk to persons in care.

Official plan of correction

Licensee stated that S1 has been terminated as of 05/20/24. During the inspection, LPA confirmed that S1 has been disassociated from the facility on Guardian. POC CLEARED.

Deadline recorded: Aug 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

Not listed

Regulation authority

CCR

What the official deficiency says

This page was amended due to this first citation being created in error.

Official classification

Type B

Official code

87555(b)(17)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) … (17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service… This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure the facility had a full-time chef for over a month, which poses a potential health risk to persons in care.

Official plan of correction

The licensee has already hired a full-time chef and LPA confirmed. POC CLEARED

Deadline recorded: May 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(c)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by: Deficient Practice Statement Based on documents, the facility does not have an Infection Control Plan, which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 05/28/2024 Plan of Correction Licensee stated they will review Provider Information Notice (PIN) 22-18-ASC, as well as related PINs, and submit the Infection Control Plan to LPA by POC due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on documents, the licensee did not ensure the files of S1, S2, S4, and S5 contained documentation of the required number of hours and topics of annual training, which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 05/28/2024 Plan of Correction Licensee stated they will complete and document all required annual training for these staff and submit proof to LPA by POC due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on documents, the licensee's last emergency disaster drill was almost 4 months ago (not quarterly) and only involved 2 out of 3 shifts, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 05/28/2024 Plan of Correction Licensee stated they will conduct emergency disaster drills for all 3 shifts and submit proof to LPA by POC due date.

Official classification

Type B

Official code

97555(b)

Regulation authority

CCR

What the official deficiency says

87555 General food Service Requirements (b) The following food service requirements shall apply: (8) All food shall be of good quality. This requirement was not met as evidenced by: Based on interviews, facility did not provide adequate food service when food was prepared by S1 which poses a potential Personal Rights risk to persons in care.

Official plan of correction

Adminstrator stated that they will submit an Acknowlegement of Understanding for the said deficiency to LPA via email by POC due date.

Deadline recorded: Mar 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on observations and review of records, two out of the five residents did not receive one medication as prescribed during the month of February 2024 which poses an immediate Health risk to persons in care.

Official plan of correction

Adminstrator to submit an Acknowledgement of Understanding for the said deficiency to LPA via email by POC due date and to conduct an in-service training covering the medication procedures and protocols including documentation and to provide a copy of the training form with the signatures of the attendees by March 15, 2024.

Deadline recorded: Mar 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services … (f) Basic services shall at a minimum include: (1) Care and supervision... This requirement was not met as evidenced by: Based on observation and interviews, the licensee did not ensure 1 out of 7 residents received care and supervision when their hygiene needs were not met, which poses an immediate health risk to persons in care.

Official plan of correction

The licensee stated that they have since initiated a shower log which documents whether showers were provided or refused in order to ensure residents are receiving their scheduled showers. During the inspection, LPA reviewed the shower log and confirmed the correction. POC CLEARED.

Deadline recorded: Dec 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(5)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements … (b) … (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for … food habits of residents. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure an appropriate variety of food when the food served was too often a sandwich or otherwise cold, which poses a potential personal rights risk to persons in care.

Official plan of correction

The licensee stated the ice machine has been replaced and the menu has been redone and now contains mainly hot foods and few sandwiches. During the inspection, LPA confirmed these corrections. The licensee stated they will create a tray service protocol to ensure food is delivered still hot to residents who do not eat in the dining room and will submit proof to LPA by POC due date.

Deadline recorded: Jan 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: based on record review and interview the Licensee did not ensure the medications for R1 were given according to physician's orders. R1 was not administered 5 medications on 10 different days. This poses an immediate risk to the health & safety of residents in care.

Official plan of correction

Licensee to ensure all medications are given in accordance to doctor's orders at all times. Licensee to submit a written statement to LPA indicating they have read this section of regulation and how they intend to adhere by providing staff training. Licensee to provide proof to LPA POC due date.

Deadline recorded: Apr 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on observations, interviews, and record review, two of two staff were not associated prior to working at the facility which poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Licensee agrees to associate two staff and to provide proof to LPA via email by POC due date.

Deadline recorded: Mar 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87218(a)(2)

Regulation authority

CCR

What the official deficiency says

87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in Section 1569.153. This requirement is not met as evidenced by: Based on interviews, three of four individuals confirmed the meat was stolen which poses a potential Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Licensee agrees to receive residents' signatures for their understanding of the faciity's theft and loss policy and to forward proof to LPA by POC due date.

Deadline recorded: Mar 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on observations and interviews, the licensee did not prevent insects from getting into the facility and causing an infestation, which poses a potential personal rights and safety risk to residents in care.

Official plan of correction

Licensee has already had Orange County spray for mosquitos and has developed a plan to permanently close off the open-air central patio. In addition, Licensee stated they will continue to have the insects addressed by their pest control company and Orange County and will explore additional measures with their pest control company. POC CLEARED.

Deadline recorded: Sep 26, 2022. A deadline is not proof that correction was completed.