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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005171
Report Date: 12/28/2023
Date Signed: 12/28/2023 09:42:24 AM

Document Has Been Signed on 12/28/2023 09:42 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
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: 4DATE:
12/28/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Evangeline Bation - DSPTIME COMPLETED:
10:00 AM
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Licensing Program Analyst, (LPA) Dwayne Mason Jr. arrived at the facility for the purpose of conducting a follow up Plan of Corrections (POC) inspection. LPA was greeted and granted entry by Elmar Santos, DSP. LPA stated the purpose of the inspection. DSP Santos had to leave the facility, so LPA communicated with Evangeline Bation, DSP and the Administrator Joyce Zablan via phone call.

LPA observed clients to be away at Day Program or still asleep. LPA toured facility and observed the facility to be clean, sanitary and safe.

LPA observed the hole in the wall behind the door in Bedroom 5 to be patched and reinforced with a mounted door stopper to avoid the damage occurring again.

Based on today's inspection, the LPA determined that the facility has fulfilled the Plan of Correction by the assigned POC due date. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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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