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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003759
Report Date: 08/10/2023
Date Signed: 08/10/2023 04:00:36 PM

Document Has Been Signed on 08/10/2023 04:00 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 HOMES-CARDALEFACILITY NUMBER:
306003759
ADMINISTRATOR:SHIRRELL Y. SMITHFACILITY TYPE:
735
ADDRESS:6234 CARDALE STREETTELEPHONE:
(562) 455-5515
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 4CENSUS: 4DATE:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Shirrel Smith - LicenseeTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Shirrel Smith (Licensee) and explained the reason for the visit. The facility is licensed to serve three (3) ambulatory and one (1) non-ambulatory developmentally disabled adults ages 18 through 59. The facility is operating within the scope of the license.

A tour of the single-story facility included the living room, family room, kitchen, 4 bedrooms, 2 bathrooms, laundry area, front yard, backyard and a detached garage/storage. LPA Mora conducted the tour with Shirrel Smith and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps, chemicals and cleaning solutions are kept locked in a cabinet in the backyard patio. The First Aid kit is kept locked in the medication cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway closet. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a cabinet located in the family room. Client and staff files are kept in a family room cabinet. All bedrooms have all required furniture, lighting, and bedding. All bathrooms were observed with shower mats and grab bars for non-ambulatory clients. The water temperature was tested in both bathrooms and measured at 105.2 degrees F and 105.7 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the kitchen and it is fully charged. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. A carbon monoxide was observed in the family room and was not working properly. During the visit, the Licensee purchased a new carbon monoxide and installed it in the living room. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

LPA reviewed medication for 2 clients and observed that medications are documented properly and given as prescribed. Client 1 (C1) has no medication prescribed and Client 3 (C3) has been in the hospitalized since 02/23/2023. (Continued to LIC 809-C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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-CARDALE
FACILITY NUMBER: 306003759
VISIT DATE: 08/10/2023
NARRATIVE
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LPA reviewed files for all 4 clients and 5 staff files. C1 does not have a physician report and the functional capabilities form is incomplete. C2 does not have a functional capabilities form. Staff 1 and Staff 2 did not have a completed orientation training documentation on file. The orientation training record was blank. Staff 1, Staff 3 and Staff 4 did not have a valid CPR/First Aid certification on file. Staff 1, Staff 2, and Staff 3 did not have a valid CPI certification on file. LPA observed administrator certificate for Sky Julian - 6003571735 with an expiration date of 10/10/2023. LPA interviewed 2 staff and 1 client. The other 3 clients were not at the facility during the visit to be interviewed. LPA reviewed P&I funds for all 4 clients with the Administrator present and observed no discrepancies. Facility did not have the latest version of the emergency disaster plan (LIC 610-D).

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit (Refer to LIC 809-D). Exit interview held and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/10/2023 04:00 PM - It Cannot Be Edited


Created By: Luis Mora On 08/10/2023 at 03:21 PM
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-CARDALE
FACILITY NUMBER: 306003759

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Carbon monoxide was not operating properly.
POC Due Date: 08/17/2023
Plan of Correction
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Facility is to ensure that Health and Safety Code 1503.2 are met at all times. Additionally, facility will purchase a new carbon monoxide and submit proof purchase receipt to CCLD by 08/17/2023.

*During the visit, the licensee purchased a new carbon monoxide and install it.*
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 5 staff files which poses/posed a potential health, safety or personal rights risk to persons in care. Staff 1 and Staff 2 did not have a completed orientation training documentation on file. The orientation training record was blank.
POC Due Date: 08/24/2023
Plan of Correction
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Facility is to ensure that Title 22 Section Code 80065 are met at all times. Additionally, facility will complete the orientation training records and submit a copy to CCLD by 08/24/2023.
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: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/10/2023 04:00 PM - It Cannot Be Edited


Created By: Luis Mora On 08/10/2023 at 03:21 PM
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-CARDALE
FACILITY NUMBER: 306003759

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Facility did not have the latest version of the Emergency and Disaster Plan (LIC 610-D)
POC Due Date: 08/24/2023
Plan of Correction
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Facility is to ensure that Health and Safety Code 1565 are met at all times. Additionally, facility will complete the latest version of the Emergency and Disaster Plan (LIC 610-D) and submit a copy to CCLD by 08/24/2023.
Type B
Section Cited
CCR
85165(b)(2)
Emergency Intervention Staff Training
(b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training. (2) Staff shall maintain valid certification.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 staff files which poses/posed a potential health, safety or personal rights risk to persons in care. Staff 1, Staff 2, and Staff 3 did not have a valid CPI certification on file.
POC Due Date: 08/24/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 85165 regulations are met at all times. Additionally, facility will have the staff renew their CPI certification and submit a valid copy of the CPI to CCLD by 08/24/2023.
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: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/10/2023 04:00 PM - It Cannot Be Edited


Created By: Luis Mora On 08/10/2023 at 03:33 PM
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-CARDALE
FACILITY NUMBER: 306003759

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069.2(a)
In order to determine whether the facility's program meets a client's services needs, the licensee of an ARF shall assess the client's need for personal assistance and care by determining his/her functional capabilities. The assessment shall be in writing, shall be used in developing the Needs and Service Plan, and shall include, but not be limited to the following activities:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 client files which poses/posed a potential health, safety or personal rights risk to persons in care. Client 1 (C1) and Client 2 (C2) did not have or did not have a completed Functional Capabilities form (LIC 9172) on file.
POC Due Date: 08/24/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80069.2 regulations are met at all times. Additionally, facility will complete the Functional Capabilities and submit a copy to CCLD by 08/24/2023.
Type B
Section Cited
CCR
80069(b)
In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 5 client files which poses/posed a potential health, safety or personal rights risk to persons in care. Client 1 (C1) did not have a physician report in their file.
POC Due Date: 08/24/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80069 regulations are met at all times. Additionally, facility will obtain a physician report for the client and submit a copy of the physician report to CCLD by 08/24/2023.
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: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/10/2023 04:00 PM - It Cannot Be Edited


Created By: Luis Mora On 08/10/2023 at 03:50 PM
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-CARDALE
FACILITY NUMBER: 306003759

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 5 staff files which poses/posed a potential health, safety or personal rights risk to persons in care. Staff 1, Staff 3 and Staff 4 did not have a valid CPR/First Aid certification on file.
POC Due Date: 08/24/2023
Plan of Correction
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3
4
Facility is to ensure that Title 22 Section Code 80075 are met at all times. Additionally, facility will have the staff renew their CPR/First Aid certifications and submit copies of the staff valid CPR/First Aid certifications to CCLD by 08/24/2023.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
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