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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005171
Report Date: 10/03/2024
Date Signed: 10/03/2024 04:31:49 PM

Document Has Been Signed on 10/03/2024 04:31 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SKYWOOD FAMILY HOMEFACILITY NUMBER:
306005171
ADMINISTRATOR/
DIRECTOR:		ARBOLEDA, ANTONIO LFACILITY TYPE:
735
ADDRESS:1855 SKYWOOD STTELEPHONE:
(562) 694-3820
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY: 6CENSUS: 5DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Joyce Zablan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1. During today’s visit, LPA met with Jocelyn "Joyce" Zablan, Administrator.

The facility is a level 4e single story building with an approved fire clearance of three ambulatory and three non-ambulatory rooms in bedrooms one, two and five. The facility currently has a census of five clients in care. At time of arrival three clients were in Day Program and arrived after 3pm.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two client bathrooms, and testing auditory devices. The hot water temperature measured between 106.1 and 106.4 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on September 18, 2024. The facility’s last fire drill was conducted on September 5, 2024. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed.

LPA conducted a complete review of client records. One of five client records does not have a Medical Assessment and a deficiency will be given. Admissions Agreements that are compliant to Title 22 will be created by Administrator by November 5, 2024. Client P&I records were reviewed and were accurate. LPA interviewed alert clients regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which is pending renewal on August 29, 2026.

(Continued on LIC 809-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SKYWOOD FAMILY HOME
FACILITY NUMBER: 306005171
VISIT DATE: 10/03/2024
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(Continued from LIC 809)

The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Jocelyn Zablan, Administrator and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D, LIC 9102-TV and Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2024 04:31 PM - It Cannot Be Edited


Created By: RoseMarie Ruppert On 10/03/2024 at 04:17 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: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in one of five client records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2024
Plan of Correction
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Administrator will work with family conservator to assist with finding a primary care physician to conduct a medical assessment. Administrator will email LPA the medical assessment by POC date.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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