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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800232
Report Date: 05/04/2023
Date Signed: 05/04/2023 02:10:42 PM

Document Has Been Signed on 05/04/2023 02:10 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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:
05/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Lameshia Edwards-DSPTIME COMPLETED:
02:10 PM
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On 05/04/23 at 8:40 AM, Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced
case management visit in conjunction to complaint # 56-AS-20230428084205 and met with DSP, Lameshia Edwards. LPA disclosed the purpose of the inspection and was granted entry into the facility by the DSP.

At 8:55 AM, LPA observed a hole, the size of a basketball, on the hallway wall that is next to the bathroom and another hole with the same size on the wall of (R1) bedroom. DSP stated that the holes were a result of (R1) behavioral episode that occurred on 04/20/23. DSP stated that the Administrator is going to get the walls repaired.

At 9:30 AM, LPA observed staff records and found that (S1) and (S2) do not have background clearance. DSP stated that (S1) has been working since 04/17/23 and (S2) since 02/07/23.

At 10:00 AM, LPA observed through resident records and interview that Special Incident Report (SIR) were not reported to the Regional Office (RO). Administrator stated that DSP was in charge of submitting SIR's. DSP stated that reporting is only sent to IRC and not RO.

An exit interview was conducted and a copy of this report, LIC809D, LIC421BG and appeal rights were provided to the
DSP, Lameshia Edwards.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 05/04/2023 02:10 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/04/2023 at 12:11 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
RIVERSIDE, CA 92507

FACILITY NAME: SKY BLUE SUMMER CARE
FACILITY NUMBER: 361800232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2023
Section Cited
CCR
80019(e)(1)

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80019(e)(1) Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant...in a licensed facility:(1)Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidenced by:
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Administrator stated that she is dismissing (S1) and (S2) from working at the facility by 05/04/23.
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Based on observation, interview, and record review, the Administrator did not comply with the section cited above by employing 2 staff without criminal clearance and endangering 4 out of 4 residents which poses an immediate health, safety and personal rights risk to persons in care.
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Type B
05/12/2023
Section Cited
CCR80087(a)

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80087(a) Buildings 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:
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Administrator stated the holes on the walls of the hallway and bedroom will be covered with cardboard in the meantime and then proof of repair will be submitted to the LPA by 04/12/2023.
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Based on observation and interview, the
Administrator did not have the facility in good repair which poses a potential Health and Safety risk to 4 out 4 persons in care.
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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:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/04/2023 02:10 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 05/04/2023 at 01:49 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
RIVERSIDE, CA 92507

FACILITY NAME: SKY BLUE SUMMER CARE
FACILITY NUMBER: 361800232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited
CCR
80061(a)

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80061(a) Reporting Requirements
(a)Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section. This requirement is not met as evidenced by:
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Administrator stated a meeting with staff will
be held to discuss reporting requirements. Proof of staff training sign in sheet will be provided to LPA by 05/12/2023.
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Based on observation, interview, and record review, the Administrator did not comply with the section cited above by failing to report and endangering 4 out of 4 residents which poses a potential health, safety and personal rights risk to persons in care.
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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:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023


LIC809 (FAS) - (06/04)
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