365530011-6-20-2023-56-AS-PGUO-CSYND8-20230620102156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530011
Report Date: 06/20/2023
Date Signed: 06/20/2023 10:23:15 AM

Document Has Been Signed on 06/20/2023 10:23 AM - 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:	BLU SKYYZ RESIDENTIAL CARE		FACILITY NUMBER:	365530011
ADMINISTRATOR:	KENNETH A LEONARD		FACILITY TYPE:	735
ADDRESS:	16251 NIGHT STAR CT		TELEPHONE:	(800) 680-1484
CITY:	FONTANA	STATE: CA	ZIP CODE:	92336
CAPACITY: 6		CENSUS: 0	DATE:	06/20/2023
TYPE OF VISIT:	Required - 1 Year	ANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	KENNETH A LEONARD		TIME COMPLETED:	10:30 AM

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Licensing Program Analyst (LPA) Paola Guerrero made an announced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Facility Administrator Kenneth Leonard and was granted entry to the facility. At the time of the visit there was one (1) staff, and zero (0) clients present. The facility is a four (4) bedroom, three (3), bathroom home, with a kitchen/dining area, living room, and attached garage. The facility is an Adult Residential Facility (ARF) level 4i designated home vendorized by Inland Regional Center. Licensed capacity is (6) current census (0). LPA was accompanied by Facility Administrator Kenneth Leonard to conduct a general overall inspection, which included, but was not limited to, the following:

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. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be at 109.10 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients. There was a designated storage space for client/staff files. Medications are kept inside medication closet inaccessible to clients. Overall, the facility is clean, in good repair, and operating in safe conditions.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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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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: BLU SKYYZ RESIDENTIAL CARE	FACILITY NUMBER: 365530011
	VISIT DATE: 06/20/2023

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Care & Supervision: Facility currently has no clients in care. Staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed one (1) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Kenneth Leonard.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC809 (FAS) - (06/04)

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