Blue Skies of Pendleton

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Arlan Acosta. The facility has a licensed capacity of 6 residents, 2 of which may be non-ambulatory in bedroom #4 and has a hospice waiver for 6 residents. During today’s visit, the facility had a census of 6 non-ambulatory residents, 3 of which were receiving hospice services. As of 10/8/2024, the facility has a pending fire clearance request to increase the facility's capacity to 6 non-ambulatory residents. The Administrator for the facility is Laurice Gamab and their certificate was valid and current. During today’s visit, LPA inspected each room of the facility, including resident and staff rooms, private and common bathrooms, kitchen, garage, common areas, and outside space. No bodies of water, delayed egress, or secured perimeter were observed on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. LPA observed linens and hygiene products for resident use. The facility’s ambient and water temperature were measured within regulatory requirements at multiple locations. LPA observed locked storage for hazardous and/or toxic chemicals, which were stored separately from food supplies. LPA observed unlocked resident medications stored in the kitchen refrigerator. Staff Acosta stated that the medications stored in the refrigerator needed to be refrigerated and confirmed that the facility did not currently have a lockbox to secure the medications. Additionally, inspection of the medications cabinet revealed that daily doses of resident medications were stored in daily pillboxes. Continued on LIC809-C page... According to Arlan Acosta, no firearms or weapons are stored on the premises. LPA observed a minimum supply of 2-days of perishable food and 7-days of non-perishable food. The refrigerator and freezer temperatures were kept within requirements. Staff present at the facility had a criminal background clearance and association. LPA reviewed multiple resident and staff records. Staff records for Staff 1 were incomplete. [Caregiver Acosta was provided with an LIC811 Confidential Names List to identify S1]. The following deficiencies were cited for unlocked medication, medications not stored in their original container, and incomplete personnel records and noted on the attached LIC809-D pages. Additionally, an LIC9102TV Technical Violation regarding annual visits with medical professionals was provided. An exit interview was conducted with Caregiver Arlan Acosta, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Mar 5, 2026

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff did not treat resident with dignity Staff did not provide incontinence care

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to open an investigation and deliver findings regarding the above mentioned allegations. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Caregiver Arlan Acosta. During today’s visit, LPA toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed residents and staff. LPA was away from the facility from approximately 11:50am to 1:05pm. The Department's investigation consisted of interviews with residents, staff, and outside sources, records review, and tour of the facility. It was alleged that staff did not treat resident with dignity, specifically, that staff hit Resident 1 (R1), and that staff did not provide incontinence care. Continued on LIC9099-C page... Unsubstantiated Review of R1's medical assessments and needs and services plans dated 2025 and 2026 revealed that R1 was diagnosed with a major neurocognitive disorder (NCD), resulting in issues with disorientation, hazard awareness, impulse control, and expressions of frustration. Additionally, R1 was incontinent of bowel and bladder and required staff assistance with bathing, grooming, and toileting. R1 was also receiving hospice services for the major NCD diagnosis. Interviews revealed that R1 was often confused and unable to provide specific details regarding dates and times. Interviews with staff and outside sources revealed that in January 2026, R1 reported that an individual entered R1's room and hit them in the face, resulting in bruises. Interviews with staff and outside sources, as well as LPA observation, revealed that the individual R1 described did not fit the description of any staff working at the facility. Additionally, those interviews did not reveal any evidence of the existence of any bruising on R1 since R1's admission to the facility. During today's visit, LPA did not observe any bruising, cuts, or other injuries on R1's face or hands. Additionally, R1 denied that any individual had hit, cursed, or yelled at R1 while living at the facility. An outside source stated that they believed that R1 was extremely confused or experiencing hallucinations when they made the allegation. Interviews with residents, including R1, did not reveal any concerns regarding staff assistance or interactions and residents stated that staff were nice and helpful. Interviews with staff revealed that all residents at the facility wore incontinence briefs and required staff assistance with toileting, brief changes, showers and bed-bath services. Staff stated that a couple residents were able to let staff know when they required brief changes, and staff would check on residents every two hours for brief changes. Interviews revealed that for residents in bed, staff would place incontinence pads beneath residents to catch any possible leaks from the resident's incontinence brief. Staff denied putting two briefs on any residents, and stated that some residents would be checked and changed more often than every two hours. Additionally, staff stated they provided toileting and brief change assistance to residents multiple times overnight. Interviews with outside sources and residents did not reveal any concerns regarding incontinence care, or any other type of care and supervision provided by facility staff. Those interviews also did not reveal any evidence that any residents had been placed in two briefs. The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated. An exit interview was conducted with Caregiver Arlan Acosta, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 08-AS-20260122111953

Type of visit: Required - 1 Year

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 Carlito Caoili. The facility is licensed for a maximum capacity of 6 residents, 4 ambulatory and 2 non-ambulatory in bedroom #4. As of 10/8/2024, the facility has a pending fire clearance request to increase the facility's capacity to 6 non-ambulatory residents. The facility has a waiver for 6 hospice residents. During today’s visit, the facility had a census of 6 non-ambulatory residents, 5 of which were receiving hospice services. The Administrator for the facility is Laurice 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 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 initially measured at 130.6 degrees Fahrenheit in a private resident bathroom. LPA observed Caregiver Caoili turn down the hot water heater during the visit. LPA remeasured the hot water before the end of the visit and the hot water was measured at 118.8 degrees F in the private resident bathroom, 118.2 degrees F in the common bathroom, and 113.5 degrees F in the kitchen sink. The facility’s internal temperature was measured at 76 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Caregiver Sylvia Linga, no firearms or weapons are stored on the premises. Continued on LIC809-C page… 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 and facility freezer temperatures met regulatory requirements. 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. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance, 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. LPA was away from the facility for approximately one hour between 12:10pm and 1:10pm. The following deficiency was cited for hot water temperature and noted on the attached LIC809-D page. Caregiver Caoili was able to clear the deficiency during the visit, and LPA provided Caregiver Caoili with a Letter of Deficiencies Cleared. An exit interview was conducted with Caregiver Sylvia Linga, whose signature below confirms receipt of a copy of this report, the Letter of Deficiencies Cleared, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Apr 1, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rebecca Ruiz 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 Caregivers Jimmy Merino and Jamela Reyes Magulod. The facility is licensed for a maximum capacity of 6 residents, 2 of which may be non-ambulatory in bedroom #4. 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, which puts the facility over the approved capacity for non-ambulatory residents. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Nguyen N Le 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, staff rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed near or on the premises. According to Jamela Reyes Magulod, no firearms or weapons are stored on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 106.0 degrees Fahrenheit in a private resident bathroom and 112.3 degrees Fahrenheit in a common bathroom. The facility’s internal temperature was measured at 74 degrees Fahrenheit. LPA observed cleaning and laundry chemicals stored in unlocked cabinets in the laundry room. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and label. LPA observed 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 40 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the clients 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, were associated to the facility, and had a first aid certificate. Continued on LIC809-C page… LPA reviewed multiple resident and staff records. Review of resident records revealed that all 5 residents are receiving hospice services and LPA observation of resident rooms and record review revealed that 4 of 5 residents, Resident 1 through Resident 4, did not have a doctors order for bed rails. [Caregiver was provided with an LIC811 Confidential Names list to identify R1-R4] Each resident record 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. The following deficiencies for over-capacity, unlocked chemicals, and postural supports are cited per CA Code of Regulations Title 22 and noted on the attached LIC809-D pages. Additionally, civil penalties are being assessed for over-capacity and are noted on the attached LIC421IM in the amount of $500. An exit interview was conducted with Licensee Hong Hanh Le Doa via telephone and Caregiver Jamela Reyes Magulod, whose signature below confirms receipt of a copy of this report, the LIC811, the LIC421IM, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Feb 27, 2024