<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600496
Report Date: 01/17/2023
Date Signed: 01/17/2023 03:06:06 PM

Document Has Been Signed on 01/17/2023 03:06 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
GREATER LA AC/SC, 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:
(562) 455-5515
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 4CENSUS: 3DATE:
01/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ruby Manikad, Staff TIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection with the focus of the Infection Control domain. LPA met with staff, Ruby Manikad, and explained the purpose of the visit.
The facility is approved for four (4) developmentally disabled adults, ages 18 - 59, which one may be non-ambulatory. There are currently 3 clients residing at the home and receive services from the Harbor Regional Center.

LPA Chan toured the facility and observed the following:
* There are 4 client bedrooms, 2 bathrooms, living room, dining area, kitchen, and the garage. There are no pool or bodies of water on the premises. There are no items obstructing the hallways or walkways. The facility has proper Coronavirus (COVID-19) signage at the main entrance and around the home. Hand washing signs are posted in each of the bathrooms and kitchen sink. Staff are continuing to screen all visitors upon entry. Staff and clients' temperature are also taken daily and documented. Sufficient PPE supplies are stored at the facility. The smoke detectors and carbon monoxide detector are operable. Food supplies for 2 day perishable and a week of non-perishable were observed. Knives and sharps are stored along with the cleaning supplies in the laundry area. Medications are centrally stored and locked. LPA reviewed all 3 client medications and staff are administering them as prescribed by the physician. Emergency contact information for clients are most current. All staff on duty were wearing face masks. Staff are still following COVID-19 guidance and disinfecting all high touched surfaces every shift. Per Administrator, there are backup staffing if needed.

No deficiencies were issued during the visit today. An exit interview was held and a copy of this report was provided to Administrator Shirrell Smith.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2