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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800232
Report Date: 09/12/2025
Date Signed: 09/12/2025 09:44:35 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/08/2025 and conducted by Evaluator Eldin Serrano
COMPLAINT CONTROL NUMBER: 56-AS-20250708141147
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: 3DATE:
09/12/2025
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Shevonda Broaden, Direct Support ProfessionalTIME COMPLETED:
10:05 AM
ALLEGATION(S):
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Licensee withheld residents medication
Licensee withheld residents personal belongings
INVESTIGATION FINDINGS:
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On 9/12/2025 at 9:05 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to investigate and deliver the findings of the above allegations. LPA Serrano met with Direct Support Professional (DSP) Shevonda Broaden, and she immediately called the administrator, and LPA explained the purpose of the visit. The investigation consisted of file review, interviews with facility staff and residents as well as facility observation.

Allegation #1: Licensee withheld residents’ medication – Based on file review and information received during interviews LPA was unable to corroborate the allegation. All interviews with 2 staff and 2 clients indicated that the facility did not withhold residents’ medication.

Allegation #2: Licensee withheld residents personal belongings – – Based on file review and information received during interviews LPA was unable to corroborate the allegation. All interviews with 2 staff and 2 clients indicated that the facility did not withhold residents’ personal belongings. The facility provided the client’s personal property and valuables inventory that was signed by the other facility where the former clients moved into.
****continue on LIC9099C****
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
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 2
Control Number 56-AS-20250708141147
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SKY BLUE SUMMER CARE
FACILITY NUMBER: 361800232
VISIT DATE: 09/12/2025
NARRATIVE
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During the investigation, LPA did not find evidence to corroborate the allegations.

Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted where this report, LIC9099 and LIC9099C, were discussed and provided to DSP Shevonda Broaden.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2