<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800232
Report Date: 10/18/2023
Date Signed: 10/18/2023 01:18:19 PM

Document Has Been Signed on 10/18/2023 01:18 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: DATE:
10/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Claudia Walker- LicenseeTIME COMPLETED:
01:22 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced visit to the facility to conduct a case management visit and follow up on an adult client death. LPA met with Licensee, Claudia Walker who was informed of the purpose of the visit.

This case management visit consisted of collecting pertinent documentation and conducting staff and client interviews regarding the death of Client #1(C1).

Walker stated that there is no official death certificate and cause of death at this time. Walker also stated that a Police report was made and facility is waiting for Coroners to pick up the body. LPA has advised the administrator to send a copy of the death certificate to Community Care Licensing Division (CCLD) Riverside Regional Office as soon as it is available.

LPA toured the facility inside and out and there was no imminent health and/or safety concerns observed at the time of visit.

An exit interview was conducted where this report was discussed with Licensee, Claudia Walker and a copy was provided at the conclusion of the visit.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
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 1