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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005171
Report Date: 10/12/2021
Date Signed: 10/12/2021 10:21:50 AM

Document Has Been Signed on 10/12/2021 10:21 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HOMEFACILITY NUMBER:
306005171
ADMINISTRATOR:ARBOLEDA, ANTONIO LFACILITY TYPE:
735
ADDRESS:1855 SKYWOOD STTELEPHONE:
(562) 694-3820
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY: 6CENSUS: 5DATE:
10/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Staff Antonio AberinTIME COMPLETED:
10:30 AM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and was granted entry into the facility by staff. LPA's temperature was taken upon entry. LPA Tirre met with staff Antonio Aberin and explained the reason for the visit.

During the visit LPA toured the facility with staff. Facility is a 6 bedroom and 2 bathroom single story home. There are 5 Clients in care. LPA observed facility has required Department postings. LPA toured all clients rooms, all rooms where within regulations. All restrooms observed contained working water basin, soap, toilet paper and paper towels. Restrooms had proper hand washing signs posted. Clients were observed watching TV and relaxing in bedrooms.

Facility has supply of PPE but not 30 days worth, LPA reminded staff of Department guidelines. Facility has ample food supply. LPA observed facility has emergency food and water supply. Facility has emergency plan posted. Facility has a secured location for Client medication and files. Facility has 30 days supply of medications for clients. LPA reviewed Clients files during visit. Clients emergency contact information and physicians reports are current. Facility has 2 fire extinguishers fully charged. LPA observed Administrators certificate expiring April 2, 2023.


No deficiencies noted during todays visit. An exit interview was conducted with staff Aberin and copy of report was left at facility
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2021
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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