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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800232
Report Date: 05/10/2022
Date Signed: 05/10/2022 02:20:23 PM

Document Has Been Signed on 05/10/2022 02:20 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:SKY BLUE SUMMER CAREFACILITY NUMBER:
361800232
ADMINISTRATOR:WALKER, CLAUDIAFACILITY TYPE:
735
ADDRESS:16410 NISQUALLI RDTELEPHONE:
(760) 596-1659
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 4CENSUS: 4DATE:
05/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Erica, AdministratorTIME COMPLETED:
02:30 PM
NARRATIVE
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During the course of investigation for Complaint Control Number: 56-AS-20220502170001, which took place on 05/10/2022, the following was brought to Licensing Program Analyst (LPA) Rohit Lama's attention.

On 05/09/2022, an incident occurred where Resident #1 (R1) fell and hit his/her chin on the floor which resulted in laceration below the chin. The laceration appears to be 2 inches long. The laceration appears to be 1 inch wide at it widest (the mid-point). With the assistance of IIRC Employee #1 (E1), the following information was gathered:
-The incident occurred around 1700-1800
-The Licensee/Administrator was informed
-The Licensee/Administrator applied Neosporin to the laceration
-The Licensee/Administrator did take R1 to Urgent Care however R1 never stepped foot out of the vehicle
-R1 did not receive any medical care or examination
-The Licensee/Administrator failed to seek out appropriate medical care for R1
-Photographic evidence was obtained.

Based on the evidence gathered during the investigation a deficiency is being cited. Title 22 Regulation 80075(a) of Division 6, Chapter 1, Article 6 is being cited on the accompanying LIC 809-D.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/10/2022 02:20 PM - It Cannot Be Edited


Created By: Rohit Lama On 05/10/2022 at 01:37 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
, 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 A
05/11/2022
Section Cited
CCR
80075(a)

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Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This regulation was not met as
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The Administrator was directed to take immediate action and ensure that R1 receives the appropriate medical care immediately. The admiistrator will also, by Plan of Correction (POC) due date, provide an In-Service Training reagrding Health Related Services to all staff members.
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evidenced by: observations made during investigation and information obtained during interviews. This is an immediate health and safety risk to clients in care.
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If staff is not scheduled to work by POC due date, then Administrator will provide training to staff member on the first day back. The proof will be submitted to LPA in the form of a scanned document stating training provided along with staff members printed name and signature.

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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: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


LIC809 (FAS) - (06/04)
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