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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005171
Report Date: 10/19/2022
Date Signed: 10/19/2022 10:46:29 AM

Document Has Been Signed on 10/19/2022 10:46 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:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Caregiver Antonio Aberin and Administrator Michelle PunoTIME COMPLETED:
11:10 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 Tirre met with Caregiver Antonio Aberin and explained the reason for the visit.

Facility is a Level 4G Adult Residential Facility. LPA toured the facility with Caregiver Antonio Aberin. During visit Administrator Michelle Puno arrived. Facility is a 6 bedroom (5 client rooms, 1 staff room) 2 bathroom single story home. There are 5 Clients in care. During visit 3 clients were present. LPA observed facility has required Department postings. Facility has Emergency Disaster Plan, Evacuation Plan and Clients Personal Rights posted. Covid posters are posted throughout facility. Upon entry facility has visitor sign in and sanitization table with PPE. LPA toured all clients rooms, all rooms where within regulations. All restrooms observed contained working water basin, soap, toilet paper and towels. Restrooms had proper hand washing signs posted. Clients were observed watching TV and relaxing in bedrooms.

Facility has small supply of PPE , LPA reminded staff of Department guidelines. Facility has ample food supply. LPA observed facility has emergency food and water supply. 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. LPA reviewed 5 of 5 clients files. Clients emergency contact information and physicians reports are current. Facility has 2 fire extinguishers fully charged. Facility has designated visiting area.


No deficiencies noted during todays visit. An exit interview was conducted with Administrator and copy of report along with LIC 811 confidential names list was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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