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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600496
Report Date: 10/13/2023
Date Signed: 10/13/2023 09:23:49 AM

Document Has Been Signed on 10/13/2023 09:23 AM - 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:
10/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Andrew Thomas - Lead StaffTIME COMPLETED:
09:37 AM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent case management visit regarding an incident report dated 8/23/21 about a client sustaining a fracture. LPA Mora met with Andrew Thomas (Lead Staff) and explained the reason for the visit.

The investigation consisted of the following: On 08/27/21, LPA Mora conducted a Health and Safety Check 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. On 08/27/21, the Investigation Bureau (IB) accepted the referral for a full investigation.

The investigation revealed the following: regarding allegation “neglect/lack of supervision leading to a client’s fracture”, it is alleged that a staff hit a client with a stick which cause a right arm fracture. IB investigator conducted a full investigation and the investigation consisted of the following: obtained copies of all the medical records for the client, copy of police incident report, and interviewed 3 clients (including the victim), 11 facility staff, facility licensee, 2 regional center representatives, client’s family member, and client’s surgeon. Based on records and interviews conducted, on 08/22/21 morning staff stated that Client 1 (C1) told them that his/her arm hurts and they did a body check and noticed bruises and C1 told them that Staff 1 (S1) hit him/her. On the morning of 08/23/21, staff stated that the pain got worse, and the client was taken to urgent care by the Administrator. At the hospital it was determined that C1 had a fracture. C1’s surgeon diagnosed C1 with a "nightstick" injury, but the surgeon could not exclude self-harm as a cause of C1’s injury. S1 denied any abuse on the client and there was insufficient evidence to determine if S1 caused C1's fracture. Regional center did their own investigation and could not substantiate that S1 cause the injury. The police department did their own investigation and forwarded the report to the District Attorney who dismissed/rejected the charges for S1. (Continued to LIC 9099-C)

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOMES
FACILITY NUMBER: 198600496
VISIT DATE: 10/13/2023
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However, all the staff interviewed confirmed that the client was never taken away from the facility from the date of the fracture until his diagnosis. Based on the evidence received from interviews and records, it could not be determined how the client got the fracture. However, the fracture occurred while the client was at the facility, and the allegation of neglect/lack of supervision leading to the client’s fracture was substantiated.

Based on interviews and records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 1 are being cited (Refer to LIC 809-D). An immediate Civil Penalty of $500.00 is being issued today, due to client sustained a fracture while in care (Refer to LIC 421IM).
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/13/2023 09:23 AM - It Cannot Be Edited


Created By: Luis Mora On 05/31/2023 at 08:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SKY HOMES
FACILITY NUMBER: 198600496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2023
Section Cited
CCR
80072(a)(2)

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(a) ...each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations...meet his/her needs.

This requirement is not met as evidenced by:
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Facility is to ensure that Title 22 Section 80072 regulations are met at all times. Additionally, facility will conduct an in-sevice training with all staff and submit a training sing-in sheet with all staff signatures by 10/20/2023.
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Based on interviews and record review, the licensee did not comply with the section cited above in 1 out of 3 clients which poses an immediate health, safety or personal rights risk to persons in care. A client sustained a fracture while in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023


LIC809 (FAS) - (06/04)
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