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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800232
Report Date: 07/06/2023
Date Signed: 07/06/2023 05:05:27 PM

Document Has Been Signed on 07/06/2023 05:05 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:
07/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Claudia Walker-AdministratorTIME COMPLETED:
05:15 PM
NARRATIVE
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On 07/06/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Claudia Walker, introduced self and stated the purpose of the visit. LPA was informed that there is currently 4 clients in the facility.

The facility has 4 client bedrooms, 2 bathrooms, office, kitchen, dining area, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of the facility, review of records and medication audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 79 degrees fahrenheit. LPA inspected the clients bedrooms; 3 out of 4 are equipped with required furniture such as: mattresses, night stands, chairs, storage space, and sufficient lighting. LPA observed a missing chair in one of the bedrooms. Technical violation issued. LPA also observed 2 out of 4 broken dressers. Deficiency issued. LPA inspected clients bathrooms; bathrooms were clean and appliances were functional. An adequate supply of linens and blankets stored in a cabinet in the hallway of the residence. Water temperature in kitchen faucet tested at 135.9 degrees fahrenheit. Deficiency issued. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher, first aid kit, and emergency kits. Posters such as; the personal rights, disaster plan and CCL complaint poster were posted in a common area. LPA observed an incorrect Emergency Disaster Plan posted in the office. Deficiency issued. Cleaning supplies, toxins, sharps, medication and other dangerous items were kept in secure cabinets inaccessible to clients. There was a designated storage space for clients/staff files inside a filing cabinet in the office. The facility has a working telephone line. There are no pools or bodies of water, firearms or ammunition in the facility.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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 6
Document Has Been Signed on 07/06/2023 05:05 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 07/06/2023 at 03:03 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: 07/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the administrator did not comply with the section cited above in providing a minimum of one week of nonperishable foods and a minimum of two days of perishable foods to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2023
Plan of Correction
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Administrator stated that she will provide one week of nonperishable foods and a minimum of two days of perishable foods. Administrator stated that she will provide a copy of the receipts and photo of the food to the LPA via email by POC due date.
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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 07/06/2023 05:05 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 07/06/2023 at 03:03 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: 07/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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:
Deficient Practice Statement
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Based on observation and interview, the administrator did not comply with the section cited above in providing dressers in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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Administrator stated that she will purchase two dressers in good repair for clients. Administrator stated that she will provide a copy of the receipts and picture of the dressers to LPA via email by POC due date.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above in maintaining the hot water within regulations which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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Administrator lowered the temperature on the water heater. Administrator stated that she will train the staff how to check the hot water correctly. Administrator will submit a copy of the training attendance sheet to LPA via email by POC due date.
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: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/06/2023 05:05 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 07/06/2023 at 03:03 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: 07/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above in posting the correct emergency and disaster plan which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2023
Plan of Correction
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Administrator stated that she will print and post the correct emergency and disaster plan. Administrator will provide a copy to LPA via email by POC due date.
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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 361800232
VISIT DATE: 07/06/2023
NARRATIVE
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Food Service: Non-perishable and perishable food supply is insufficient for number of clients in care. Deficiency issued. Dishes, cups, and utensils were stored properly.

Yards/Outside: One shaded patio, a side gate with self-latching handle on the left and right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed 2 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed Administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff. The facility last conducted a fire and earthquake drill on July 02, 2023.

Technical violation and deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV and appeal rights were discussed and copies were provided to the Administrator, Claudia Walker.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
LIC809 (FAS) - (06/04)
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