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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003759
Report Date: 05/24/2022
Date Signed: 05/24/2022 03:54:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2022 and conducted by Evaluator Luis Mora
COMPLAINT CONTROL NUMBER: 28-AS-20220520094346
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: 3DATE:
05/24/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Josett Hyde - CaregiverTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are mismanaging residents' medication
Facility is unkempt
Staff failed to provide a safe environment for residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Caregiver Josett Hyde and explained the reason for the visit.

The investigation consisted of the following: LPA obtained a copy of the client and staff rosters, medication records, reviewed all clients medications, and conducted a tour of the facility. LPA interviewed the Administrator via phone, Staff 1 - Staff 2 (S1 - S2) and Client 1 - Client 3 (C1 - C3).

The investigaion revealed the following: regarding the allegation "staff are mismanaging resident's medication", it is alleged that staff make medication errors, administer expired medication to the residents, and do not dispose of the old medications which are placed in the cabinets. LPA reviewed medication and medication records and found that C1 missed the evening medication Aripiprazole 5 MG Table #16 on 05/06/22 and C3 missed the morning medication Pantoprazole SOD DR 40 MG Tab #31 on 05/08/22.
(CONTINUED TO LIC 9099C)


Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 28-AS-20220520094346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOMES-CARDALE
FACILITY NUMBER: 306003759
VISIT DATE: 05/24/2022
NARRATIVE
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The medication for those days was still in the bubble pack for both clients. Review of C1 and C3 medication record for May 2022 showed that there were multiple days, especially in the evening, that staff failed to sign the medication record, but the medication was given. LPA also observed discontinued medication for C2 and C3 dating back to January 2022 in the locked medication cabinet. In that same locked medication cabinet the facility keeps discontinued and old medication for a former client who no longer resides here. This client moved out on 03/18/2022. LPA did not observed any expired medication.

Regarding the allegation "facility is unkempt", it is alleged that the facility is cluttered, and they leave trash by the side of the facility’s garage. During the facility tour, the LPA observed on the side of the facility near the garage a cluttered of old chairs, old lawn mower, bunch of boxes with trash, clothes, binders and other stuff, and old vacuums. Interviews conducted with staff revealed that these items have been out there for about a week because the garage was cleaned and these things were removed from the garage.

Regarding the allegation "staff failed to provide a safe environment for residents", it is alleged that cleaning supplies at the facility are not being locked and the clients have access to it. During the tour, the LPA observed a gallon of Sun Triple Clean laundry detergent in the backyard porch near the exit door. Interviews conducted with staff revealed that they usually keep it locked but it was placed there because it did not fit in the cabinets where they lock all other chemicals and cleaning supplies.

Based on LPA's observation, records review and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview conducted and copy of appeal rights and this report were provided.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20220520094346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOMES-CARDALE
FACILITY NUMBER: 306003759
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2022
Section Cited
CCR
80075(b)
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80075 - Health Related Services.
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
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Administrator will train staff members on medication procedures. A training sign in sheet will be submitted to LPA by 05/31/2022.
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C1 and C3 medication records had mutliple days that staff did not sign, but medication was given. Furthermore, C1 was not given an evening medication on 05/06/22 and C3 was not given a morning medication on 05/08/22, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
05/31/2022
Section Cited
CCR
80075(l)
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80075 - Health Related Services.
(l) Prescription medications which are not taken with the client upon termination of services, or which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client.
This requirement is not met as evidenced by:
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Administrator is to submit proper documentation of destruction with proof of witness. Documentation needs to be submitted to LPA by 05/31/2022.
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Facility is keeping discontinued and old medication for C2, C3 and a former client who no longer resides at this facility, which poses an immediate health, safety or personal rights risk to persons 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.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20220520094346
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOMES-CARDALE
FACILITY NUMBER: 306003759
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2022
Section Cited
CCR
80087(g)
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80087 - Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Administrator will train staff members on locking chemicals and cleaning supplies procedures. A training sign in sheet will be submitted to LPA by 05/31/2022.
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During the tour, LPA observed a gallon of Sun Triple Clean laundry detergent in the backyard porch near the exit door which poses an immediate health, safety or personal rights risk to persons in care.

Detergent was locked during the visit.
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Type B
05/31/2022
Section Cited
CCR
80087(a)
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80087 - Buildings and Grounds.
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
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Administrator will clean up the cluttered and submit a photo of the area showing that it has been cleaned. The photo will be submitted to LPA by 05/31/2022.
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During the tour, LPA observed on the side of the facility near the garage a cluttered of old chairs, old lawn mower, bunch of boxes with trash, clothes, binders and other stuff, and old vacuums.
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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.
NAME OF LICENSING PROGRAM MANAGER: Stefanie Coronel
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4