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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004187
Report Date: 06/05/2023
Date Signed: 06/05/2023 02:49:45 PM


Document Has Been Signed on 06/05/2023 02:49 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:SKY HOMES-DENMEADFACILITY NUMBER:
306004187
ADMINISTRATOR:SKY JULIANFACILITY TYPE:
735
ADDRESS:2409 DENMEAD STREETTELEPHONE:
(562) 455-5515
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY:4CENSUS: 4DATE:
06/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Shirrel Smith - LicenseeTIME COMPLETED:
03:05 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 Jacqueline Aquino (Caregiver) and explained the reason for the visit. Shortly after Shirrel Smith (Licensee) and Sky Julian (Administrator) showed up. The facility is licensed to serve three (3) ambulatory and one (1) non-ambulatory developmentally disabled adults with restricted health conditions. The facility is operating within the scope of the license. There is 1 client that has been at a physical therapy hospital since 05/16/2023.

A tour of the single-story facility included the living room, den, kitchen, dining area, 4 client bedrooms, 2 bathrooms, laundry area, front yard, backyard, and detached garage. LPA Mora conducted the tour with Jacqueline Aquino 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 laundry cabinet. 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 laundry cabinet. Client and staff files are kept in a dining area 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 113.3 degrees F and 112.6 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. There is a carbon monoxide in the den and was operable during the visit. 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 all 4 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 4 clients and 5 staff files. LPA observed administrator certificate for Sky Julian - 6003571735 with an expiration date of 10/10/2023. LPA interviewed 2 staff, 1 client and attempted to interview the other 2 clients. LPA reviewed P&I funds for all 4 clients with the Administrator.
(Continued to LIC 809-D)
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023
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 4


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-DENMEAD
FACILITY NUMBER: 306004187
VISIT DATE: 06/05/2023
NARRATIVE
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During the visit, the surety bond, plan of operation and the latest version of the emergency disaster plan (LIC 610-D) were not at the facility for review.

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.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/05/2023 02:49 PM - It Cannot Be Edited

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-DENMEAD
FACILITY NUMBER: 306004187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80022(a)
Plan of Operation
(a) Each licensee shall have and maintain on file a current, written, definitive plan of operation.

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 which poses/posed a potential health, safety or personal rights risk to persons in care. The Plan of Operation was not the facility for the LPA to review during the visit.
POC Due Date: 06/13/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80022 regulations are met at all times. Additionally, the Licensee will submit a copy of the Plan of Operation to CCLD by 06/13/2023.
Type B
Section Cited
CCR
80025(b)
Bonding
(b) All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal.

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 which poses/posed a potential health, safety or personal rights risk to persons in care. The surety bond was not the facility for the LPA to review during the visit.
POC Due Date: 06/13/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80025 regulations are met at all times. Additionally, the Licensee will submit a copy of the surety bond to CCLD by 06/13/2023.
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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/05/2023 02:49 PM - It Cannot Be Edited

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-DENMEAD
FACILITY NUMBER: 306004187

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2023

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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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. The facility did not have the latest version of the Emergency Disaster Plan (LIC 610D).
POC Due Date: 06/13/2023
Plan of Correction
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Facility is to ensure that Health and Safety Code 1565 are met at all times. Additionally, the Licensee will submit a copy of the Emergency Disaster Plan to CCLD by 06/13/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Luis MoraTELEPHONE: 323-981-3964
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4