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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005792
Report Date: 09/30/2026
Date Signed: 09/30/2026 09:59:51 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/22/2026 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20260922143230
FACILITY NAME:BLUE SKY MANOR INCFACILITY NUMBER:
306005792
ADMINISTRATOR:GABRIEL AIRAPETIANFACILITY TYPE:
740
ADDRESS:280 N WILSHIRE AVETELEPHONE:
(714) 844-2667
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:50CENSUS: 47DATE:
09/30/2026
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Sonya Tatunts - Adminstrator Assistant TIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Facility did not administer medication in a timely manner.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigaiton. LPA was greeted and granted entry into the facility and explained the reason for the visit.
The Department received a complaint on September 22, 2026. During the visit, LPA Mendivil obtained copies of Resident 1 (R1)'s admission agreement, physician's report, medication administration records and narcotics log. LPA also interviewed staff and residents. Regarding the allegation that facility did not administrater medicaiton in a timely manner, the investigation revealed the following:

It was reported that R1 was not receiving their medicaitons timely. Per review of Medication Administration Records (MAR) R1 is prescribed Hydrocodone as a PRN every 6 hours, meaning as needed. Per interviews with three out of three staff, staff stated they give the medications as prescribed. Per interviews with staff, staff stated that they had issues when R1 would ask for the Hydrocodone before the six hour period was up.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20260922143230
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BLUE SKY MANOR INC
FACILITY NUMBER: 306005792
VISIT DATE: 09/30/2026
NARRATIVE
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Staff stated that they had spoken to R1 regarding speaking with their physician to make the PRN a routine medication to help with the pain. Per the Medication Administration Record R1 was also prescribed aspercreme lidocaine patch PRN and acetaminophen PRN, which staff stated R1 does not ask for or does not want to take. Interviews with three out of three residents stated they get their medications as prescribed.

Therefore based on the preponderance of evidence through records reviewed and interviews the allegation that Facility did not administer medication in a timely manner, is determined to be UNFOUNDED meaning that the allegations were false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2