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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600496
Report Date: 08/27/2021
Date Signed: 08/27/2021 01:11:57 PM

Document Has Been Signed on 08/27/2021 01:11 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SKY HOMESFACILITY NUMBER:
198600496
ADMINISTRATOR:SMITH, SHIRRELLFACILITY TYPE:
735
ADDRESS:6338 SOUTH STREETTELEPHONE:
(714) 469-1056
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 4CENSUS: 3DATE:
08/27/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Patricia WinstonTIME COMPLETED:
01:25 PM
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A case management visit was conducted by Licensing Program Analyst (LPA) Luis Mora as a follow up to the incident report dated 8/23/21 in regard to a client sustaining a fracture. At the time of the visit, LPA conducted a Health and Safety check. LPA met with Administrator Patricia Winston and explained the reason for the visit.

LPA did the following at the time of the visit: LPA requested a copy of staff and client rosters and conducted a tour of facility and common areas. LPA observed a sufficient supply of perishable and non-perishable foods. LPA observed the clients to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns.

More information is needed; therefore, LPA will return to the facility to complete investigation. Exit interview conducted and copy of report provided to the Administrator.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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