Blue Skies of the Hill

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 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... 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).the state’s words, verbatim · CDSS document, Jul 24, 2025

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Lack of Supervision, resulting in hospitalization

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). Unfoundedthe state’s words, verbatim · CDSS document, May 23, 2025 · control 08-AS-20250522161505

Type of visit: Prelicensing

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).the state’s words, verbatim · CDSS document, Apr 4, 2024

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: INITIAL Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Name -Hong Hanh LeDao (Applicant) & Rafael Gamab (Administrator) Interview Method: Telephone interview On January 10, 2024, Applicant & Administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of the following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-Licensing Readinessthe state’s words, verbatim · CDSS document, Jan 10, 2024