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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800232
Report Date: 04/19/2022
Date Signed: 04/19/2022 01:23:17 PM

Document Has Been Signed on 04/19/2022 01:23 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:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee Claudia WalkerTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility to initiate annual inspection, LPA met with Licensee Claudia Walker

LPA observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. One central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening has been initiated at entry for all staff, clients, and visitors. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and clients.

LPA toured the facility inside and out and there were no health and safety concerns. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. The outdoor and indoor hallways were also free of obstruction.

Cleaning supplies are locked in the closet near door entry.

The facility had a complete first aid kit and emergency supplies for LPA observed a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review.

The client rooms had the required furniture and sufficient lighting. The bathrooms can accommodate the needs for bathing and showers have non-slip flooring. The facility had a supply of additional linen and extra hygiene items for the clients. LPA measured the hot water temperature in the client bathroom. The hot water temperature measured at 118.2 degrees F.

LPA observed that one staff member was not associated and cited

Based on interviews and observations made during today’s inspection, one deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy of this report was provided to Licensee Claudia Walker at the conclusion of the inspection.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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 04/19/2022 01:23 PM - It Cannot Be Edited


Created By: Bernadette Allen On 04/19/2022 at 12:31 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: 04/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(1)


This requirement is not met as evidenced by: S1 not associtaed with facility
Deficient Practice Statement
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Criminal Record Clearance. All individuals subject to a criminal record review shall, prior to working, residing or volunteering in a licensed facility, obtain a California clearance or a criminal record exemption.
POC Due Date: 04/20/2022
Plan of Correction
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Licensee will associate the staff member online through gaurdian system.
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:Karen Clemons
LICENSING EVALUATOR NAME:Bernadette Allen
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022


LIC809 (FAS) - (06/04)
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