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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800232
Report Date: 11/30/2023
Date Signed: 11/30/2023 03:35:39 PM

Document Has Been Signed on 11/30/2023 03:35 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: 0DATE:
11/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:04 PM
MET WITH:Claudia Walker- LicenseeTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced inspection visit to inspect that the facility did not have any clients and was vacant. LPA met with Licensee, Claudia Walker and introduced self and disclosed the purpose of the visit.

LPA toured the facility with Licensee and confirmed that there were no clients present. LPA observed belongings left for two clients in their bedroom. Licensee states that she is in the process of sending the belongings to the clients.

No deficiencies were issued during this visit. A copy of this report was discussed and provided to Licensee.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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