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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800232
Report Date: 01/04/2023
Date Signed: 01/05/2023 11:10:16 AM

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
12/30/2022 and conducted by Evaluator Amy Goldenberg
COMPLAINT CONTROL NUMBER: 56-AS-20221230103806
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:
01/04/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Gerren Thoman, CaregiverTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Individual working at facility without criminal record clearance
INVESTIGATION FINDINGS:
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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), to initiate the 10 day visit to investigate the above-mentioned complaint allegation. LPA met at the door by Caregiver Gerren Thomas. LPA spoke with Licensee via telephone and disclosed the nature of the allegations. During this investigation LPA interviewed staff, and one (1) of three (3) residents present during this initial visit. LPA additionally received photographs of the staff schedule and resident roster. LPA reviewed Guardian search results. Review of the search revealed that Caregiver Gerren Thomas's criminal record status is pending and is working in this facility without proper clearance. We have substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 56-AS-20221230103806
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: 01/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/04/2023
Section Cited
CCR
80065(i)(1)
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Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: Obtain a California clearance or a criminal record exemption...
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Licensee to immediately remove this employee from the facility until a criminal record clearance is obtained.
*A Civil Penalty Assessment accompanies this deficiency.
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Caregiver Gerren Thomas's criminal record status is pending and not cleared for employment in a licensed care facility. This poses a risk to the health and safety of clients 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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2