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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005171
Report Date: 10/16/2023
Date Signed: 10/16/2023 04:04:52 PM

Document Has Been Signed on 10/16/2023 04:04 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
ORANGE COUNTY ASC, 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:
10/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:TIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at Skywood Family Home to conduct an unannounced Required 1 Year Inspection. LPA arrived at the facility at 1:30pm, LPA was greeted and granted entry by Lead Caregiver (LC) Antonio Aberin. Administrator (AD) Joyce Zablan joined the inspection via phone call.

The facility is a one-story home with five client bedrooms, two bathrooms, living room, dining room, kitchen, laundry room, staff room, backyard and attached two car garage. Facility fire extinguishers were observed to be fully charged and purchased on 3/30/23 per the attached receipts. LPA did not observe any hazards or obstacles throughout the facility. Bedrooms had the necessary furnishings. LPA observed two rooms (one vacant, one occupied) to not have screened windows. LC stated a client that no longer lives here used to remove the screens. LC stated that client moved out of the facility over a month ago. LPA observed a hole in the wall behind the door in bedroom 5. LC stated that the client residing in that room repeatedly puts that hole in the wall. LPA advised that they patch the hole and reinforce the wall with a guard patch. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and will be stored and locked under the kitchen sink, in the laundry room and garage. Medication, files and first aid kit are stored in a locked cabinet in the staff room. LPA reviewed two client files and medication. LPA reviewed three staff files. LPA interviewed two clients. Smoke and carbon monoxide detector tested operational.

LPA observed a client walk through another client's room to use the bathroom in their room. LPA issued a Technical Assistance (TA) regarding CCR 85087(a)(4). Upon record review, LPA observed the Infection Control Plan was not in the Plan of Operations at the facility. LPA issued a TA regarding CCR 85095.5(c).

Based on the observations made during today's visit, one deficiency is being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted with Lead Caregiver Antonio Aberin, and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2023
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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Document Has Been Signed on 10/16/2023 04:04 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 10/16/2023 at 03:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SKYWOOD FAMILY HOME
FACILITY NUMBER: 306005171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in the following instances: 1. there is a hole in the wall behind the door in bedroom 5, 2. two bedroom windows are not screened. This poses a potential safety and personal rights risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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Licensee stated they will patch the hole in the wall in bedroom 5 and mount a protective surface on the wall to protect it from repeated damage. Licensee stated they will add screens to the windows without screens. Licensee stated they will send to LPA via email photographic proof of the repaired and reinforced wall in bedroom 5 by the POC due date of 10/23/2023. Licensee stated they will send photographic proof that the windows have been screened by the POC due date 10/23/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023


LIC809 (FAS) - (06/04)
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