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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003759
Report Date: 07/18/2025
Date Signed: 07/18/2025 03:49:34 PM

Document Has Been Signed on 07/18/2025 03:49 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SKY HOMES-CARDALEFACILITY NUMBER:
306003759
ADMINISTRATOR/
DIRECTOR:		SKY JULIANFACILITY TYPE:
735
ADDRESS:6234 CARDALE STREETTELEPHONE:
(562) 455-5515
CITY:LAKEWOODSTATE: CAZIP CODE:
90713
CAPACITY: 4CENSUS: DATE:
07/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:32 PM
MET WITH:Sky Julian, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Mayra Cota conducted an unannounced required annual inspection with Sky Julian, Administrator who facilitated the visit. The reason for the visit was explained.

The facility is licensed to serve (3) ambulatory and (1) non-Ambulatory developmentally disabled adults, ages 18 through 59. Facility currently has 3 ambulatory clients serviced by Harbor Regional Center. The facility is operating within the scope of its license. The facility is in a residential area of Lakewood, CA.

During the visit, LPA toured the facility's indoor and outdoor environment, reviewed (3) client and (5) staff files and conducted medication review for (3) clients. The facility is a single-story house which consists of: living room/computer area, dining room, kitchen, (2) full bathrooms, (4) client bedrooms, laundry room, front and backyard, deck/patio area and detached garage.

During today’s visit, LPA observed the following:



Inside the home:
  • Living room furniture is clean and in good repair. There is sufficient seating for clients in care.
  • Kitchen appliances are clean and were operating at the time of visit.
  • Sharps were observed locked in the garage and are inaccessible to clients.
  • Sufficient supply of 2 day perishable and 7 day non-perishable food was observed. ***Continues on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SKY HOMES-CARDALE
FACILITY NUMBER: 306003759
VISIT DATE: 07/18/2025
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  • Cleaning supplies, laundry liquids and other toxins were observed locked in the garage.
  • Laundry room appliances were observed to be in operable condition.
  • Client bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space.
  • Client beds have the required linen and mattress pads. There is a closet in the hallway with extra clean linen and towels. Extra personal hygiene items for clients are stored in the garage.
  • Two full bathrooms were inspected and were observed clean. The water temperature was tested in both bathrooms and measured 105.8 degrees F in bathroom #1 and 105.3 degrees F in bathroom #2 which is within the required 105 - 120 degrees F.
  • Interconnected smoke detectors were observed throughout the facility and were tested and observed to be working properly. Carbon monoxide detector was also tested and working properly. There is one fire extinguisher located in the kitchen which was observed to be charged. Lasts fire extinguisher inspection was conducted on 3/6/25.
  • Drills are conduced monthly. Last fire/safety drill was conducted on 7/1/25.
  • First Aid kit was reviewed and contained required tools and manual.
Outdoor environment:
  • The front and backyard are well maintained and there are no pools or large bodies of water.
  • There is a shaded seating area accessible to clients, located on the patio deck. Patio furniture is in good repair and there is enough seating for clients in care.
  • Passageways and exits are free of debris and obstruction.
Record Review:
  • Three (3) client records were reviewed. Client 1 record was missing a current Physician's Report.
  • Three (3) Staff records were also reviewed. Staff are fingerprint cleared and associated to the facility.
  • Emergency Disaster Plan was reviewed and observed to be missing several pages.
Medication Review:
  • Medication is centrally stored and locked in cabinet in the dining room.
  • Medication for (3) clients was reviewed and observed to be dispensed and documented accordingly.

Per California Code of Regulations, Title 22, and California Health and Safety Code, a deficiency is being cited and a technical violation is issued today. Exit interview conducted with Sky Julian, Administrator and a copy of the report and Appeal Rights were provided during visit.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/18/2025 03:49 PM - It Cannot Be Edited


Created By: Mayra Cota On 07/18/2025 at 03:23 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: 07/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee will ensure that a separate, complete, and current record is maintained in the facility for each client.

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 by not having a current Physician's Report for Client 1 in the facility record, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2025
Plan of Correction
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Licensee will email LPA a copy of the most recent Physician's Report for Client 1 by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2025


LIC809 (FAS) - (06/04)
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