306005171-4-18-2023-22-AS-AORZ-CR7TZC-20230424151005

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005171
Report Date: 04/18/2023
Date Signed: 04/18/2023 11:26:48 AM

Unsubstantiated

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
04/04/2023 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230404120143

FACILITY NAME:	SKYWOOD FAMILY HOME		FACILITY NUMBER:	306005171
ADMINISTRATOR:	ARBOLEDA, ANTONIO L		FACILITY TYPE:	735
ADDRESS:	1855 SKYWOOD ST		TELEPHONE:	(562) 694-3820
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY:	6	CENSUS: 4	DATE:	04/18/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	House Manager Antonio Aberin		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Facility did not ensure that dishes and utensils used for eating and drinking were cleaned and sanitized after each usage.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to deliver the findings on the complaint allegation above.

LPA identified himself and explained the reason for the visit with staff.
Regarding the allegation, “Facility did not ensure that dishes and utensils used for eating and drinking were cleaned and sanitized after each usage.” The investigation revealed the following:

During the initial visit April 11, 2023, LPA Haley interviewed Administrator (AD) Michelle Puno, and three facility staff on duty during the visit. During the initial visit LPA Haley also toured the interior and exterior of the facility with staff and visually inspected the cabinets in the kitchen. During the inspection of the kitchen area, LPA Haley asked staff removed water bottles from the cabinets and the water bottles were inspected for cleanliness.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230404120143

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: 04/18/2023

NARRATIVE

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LPA Haley made a follow up visit to the facility April 18, 2023 and spoke with all facility clients, toured the facility, visually inspected the kitchen area and looked inside kitchen cabinets.

Based on the information gathered during the investigation, document review and interviews, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC9099 (FAS) - (06/04)

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