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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005171
Report Date: 04/08/2022
Date Signed: 04/08/2022 03:28:33 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2021 and conducted by Evaluator Kevin Saborit-Guasch
COMPLAINT CONTROL NUMBER: 22-AS-20211028151316
FACILITY NAME:SKYWOOD FAMILY HOMEFACILITY NUMBER:
306005171
ADMINISTRATOR:ARBOLEDA, ANTONIO LFACILITY TYPE:
735
ADDRESS:1855 SKYWOOD STTELEPHONE:
(562) 694-3820
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:6CENSUS: 5DATE:
04/08/2022
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Antony Aberin, caregiver
Michelle Gozon-Puno, administrator (via phone)		TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Medication not labelled and not properly stored.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA arrived at the facility was greeted and granted entry by caregiving staff who called Administrator Michelle Gozon-Puno to notify her of the visit. LPA explained the purpose of the visit and detailed the allegation to AD over the phone.

Findings are based upon this investigation which included documentation review of the following: RCOC Incident Reports, facility information and cleared roster at the time of the incident, medication training report signed and dated 09/20/2021, Medication Administration Records and individual prescriptions, as well as phone interviews conducted with RCOC staff and facility administrator.

It is alleged that facility is not labelling and storing medication correctly. Administrator and RCOC staff both confirm that medication belonging to member of staff S1 was left unsecured at the facility on 10/21/2021.
(CONTINUED ON FORM LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
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 3
Control Number 22-AS-20211028151316
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SKYWOOD FAMILY HOME
FACILITY NUMBER: 306005171
VISIT DATE: 04/08/2022
NARRATIVE
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(CONTINUED FROM FORM LIC9099)

Subsequent visits by LPA Jenifer Tirre and RCOC staff have found no ongoing deficiencies in regards to the storage of medication on the premises, which was confirmed during the visit by LPA Saborit-Guasch

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiency per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted and a copy of this report along with Appeal Rights were left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20211028151316
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SKYWOOD FAMILY HOME
FACILITY NUMBER: 306005171
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2022
Section Cited
CCR
87915(a)(1)
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The following requirements shall apply to medications which are centrally stored: Medications shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
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Licensee will ensure the inaccessibility and safety of the centrally stored medication as well as the absence of outside medication within the facility itself.
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Both RCOC staff and AD confirm the presence of staff medication in the facility on 10/25/2021. This poses an immediate risk to the health and safety of the 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3