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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880713
Report Date: 05/22/2023
Date Signed: 05/22/2023 10:31:06 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2023 and conducted by Evaluator Anna Bueno
COMPLAINT CONTROL NUMBER: 56-AS-20230518082217
FACILITY NAME:SKY BLUE SUMMER CAREFACILITY NUMBER:
361880713
ADMINISTRATOR:WALKER, CLAUDIAFACILITY TYPE:
735
ADDRESS:25421 LYNWOOD DRTELEPHONE:
(760) 596-1659
CITY:SAN BERNARDINOSTATE: CAZIP CODE:
92404
CAPACITY:4CENSUS: 4DATE:
05/22/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Qunisha Miller - Direct Support StaffTIME COMPLETED:
10:32 AM
ALLEGATION(S):
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Facility staff member used inappropriate language toward resident.
Facility staff member hit resident.
Facility staff member yelled at resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to initiate the complaint investigation and deliver findings on the above allegations. LPA met with staff Qunisha Miller and Diana Pacheco who were informed of the purpose of today’s visit. DSP Miller phoned Licensee Claudia Walker who spoke with LPA and LPA informed Licensee of the reason for today's visit. The investigation consisted of clients and staff interviews, and review of relevant records.

The allegations are 1: Facility staff member (S1) used inappropriate language toward resident; 2. S1 hit resident; and 3. S1 member yelled at resident. S1 denied that they yell at or use inappropriate language with clients. S1 stated that she does not yell at clients. Client interviews state that S1 does not hit them nor does S1 yell or speak inappropriately to them or witness S1 acting like this with any other clients. Staff interviewed stated that they have not seen or heard S1 does not use inappropriate language or yell or hit any of the clients nor other staff. Clients and staff stated that C1 has not returned to live or visit at this facility since C1 left in December 2022. Based on the information gathered during today's visit, the allegations are unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
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-20230518082217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 361880713
VISIT DATE: 05/22/2023
NARRATIVE
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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 and a copy of this report was provided to DSP Miller.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2