361800232-5-10-2022-56-AS-NBRN-D2VR5Z-20240228114359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361800232
Report Date: 05/10/2022
Date Signed: 05/10/2022 02:10:36 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2022 and conducted by Evaluator Rohit Lama

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220502170001

FACILITY NAME:	SKY BLUE SUMMER CARE		FACILITY NUMBER:	361800232
ADMINISTRATOR:	WALKER, CLAUDIA		FACILITY TYPE:	735
ADDRESS:	16410 NISQUALLI RD		TELEPHONE:	(760) 596-1659
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92395
CAPACITY:	4	CENSUS: 4	DATE:	05/10/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Erika Reyes, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff confiscated client's personal items (game console)

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rohit Lama conducted an unannounced visit to initiate a complaint investigation and deliver the findings for the allegation listed above. LPA met with Administrator Erika Reyes and spoke with Licensee/Administrator Claudia Walker on the phone during the visit.

LPA interviewed Resident 1 (R1), Resident 2 (R2) , Resident 3 (R3), Resident 4 (R4), Staff 1 (S1) Staff 2 (S2), and Staff 3 (S3). The allegation indicates that Staff will confiscate personal items belonging to the clients. The personal items are taken away in order reprimand clients. Interviews with R1 and R4 indicate that staff does in fact take away personal items and return them soon after (i.e. the next day).

Based on the evidence gathered during investigation, the above allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 Regulation 85072(b)(6), from Division 6, Chapter 6, Article 6, is being cited on the attached LIC 9099-D.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 56-AS-20220502170001

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SKY BLUE SUMMER CARE	FACILITY NUMBER: 361800232
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/24/2022 Section Cited CCR 85072(b)(6)	1 2 3 4 5 6 7	Personal Rights: (b)... The licensee shall ensure that each client is accorded the following personal rights... (6) To possess and use his/her own personal items, including his/her own toilet articles. This regulation was not met as evidenced by: interviews conducted with residents in the	1 2 3 4 5 6 7	The Administrator will immediately confirm with all staff that they are aware of clients' personal rights in regards to personal items. The Administrator will also, by Plan of Correction (POC) due date, provide all staff with an in-service training regarding Clients' Personal Right. The Administrator will provide
	8 9 10 11 12 13 14	home. This is a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	proof of training to LPA in the form of a scanned document that states the training provided along with signed names and signatures off all the staff members who received the training.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2022 and conducted by Evaluator Rohit Lama

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220502170001

FACILITY NAME:	SKY BLUE SUMMER CARE		FACILITY NUMBER:	361800232
ADMINISTRATOR:	WALKER, CLAUDIA		FACILITY TYPE:	735
ADDRESS:	16410 NISQUALLI RD		TELEPHONE:	(760) 596-1659
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92395
CAPACITY:	4	CENSUS: 4	DATE:	05/10/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Erika Reyes, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff restrained client
Staff neglect resulted in an altercation between a Resident with another Resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rohit Lama conducted an unannounced visit to initiate a complaint investigation and deliver the findings for the allegations listed above. LPA met with Administrator Erika Reyes and spoke with Licensee/Administrator Claudia Walker on the phone during the visit.

LPA interviewed Resident 1 (R1), Resident 2 (R2) , Resident 3 (R3), Resident 4 (R4), Staff 1 (S1) Staff 2 (S2), and Staff 3 (S3). The first allegation indicates that Staff restrained client. Interviews with R1, R2, and R4 indicated that this is not true. Interviews also revealed that nothing of the sort has ever happened in the home and that they are happy in the home. Interview with R3 was inconclusive as R3 is non-verbal. R3 did, however, state that he/she is happy here.

The second allegation states that due to staff neglect, an altercation occured between two of the residents. Interviews with R1 and R4 revealed that an altercation did occur. R2 declined to answer.
CONTINUED ON LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 56-AS-20220502170001

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SKY BLUE SUMMER CARE	FACILITY NUMBER: 361800232
	VISIT DATE: 05/10/2022

NARRATIVE

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CONTINUED FROM LIC 9099-A

Interviews with S1, S2, and S3 revealed that an altercation did occur. Interviews also revealed that the altercation occurred while Clients were under the supervision of staff members. It was also stated that Staff members promptly intervened, spoke to the involved clients separately, and reported the incident via a Special Incident Report.

Based on the evidence, the above mentioned allegations are Unsubstantiated. A finding that the complaint is Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to the administrator.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Rohit Lama
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022

LIC9099 (FAS) - (06/04)

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