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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530011
Report Date: 06/10/2024
Date Signed: 06/10/2024 03:00:10 PM

Document Has Been Signed on 06/10/2024 03:00 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:BLU SKYYZ RESIDENTIAL CAREFACILITY NUMBER:
365530011
ADMINISTRATOR/
DIRECTOR:		KENNETH A LEONARDFACILITY TYPE:
735
ADDRESS:16251 NIGHT STAR CTTELEPHONE:
(800) 680-1484
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 1DATE:
06/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Pincess BowenTIME VISIT/
INSPECTION COMPLETED:
03:15 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
On 06/10/2024 at 01:00 PM, Licensing Program Analyst (LPA) Melody Brown met with Staff #2 (S2) to initiate a Case Management Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

During the facility visit on 06/10/2024, Licensing Program Analyst (LPA) Melody Brown requested Client #1 (C1) facility file to review documents and LPA Brown observed that C1 does not have Physician Report (LIC602)/Medical Assessment on C1’s facility file. S2 contacted Administrator Melanie Morris to inquire on C1's Medical Assessment or Physician Report (LIC602) whatever is available when C1 was placed at the facility by Inland Regional Center (IRC). LPA Brown explained to Administrator Morris and S2 that deficiency will be issued as in Adult Residential Facility (ARF), the Licensee must obtain and keep on file documentation of the client’s medical assessment prior to accepting client into care. Administrator Morris and S2 verbalized understanding. Administrator Morris and S2 reported to LPA Brown that they will provide a copy of C1 Medical Assessment once it's available. Also, Administrator Morris and S2 reported that C1 was placed at the facility on 03/29/2024.

Moreover, LPA Brown observed no Admission Agreement completed on C1's facility file. LPA Brown explained to Administrator Morris and S2 that deficiency will be issued as the Licensee's required to complete an individual written admission agreement for C1 and C1's authorized representative, if any. S2 and Administrator Morris verbalized understanding.

An exit interview was conducted where this report (LIC809), LIC809D and Appeal Rights were discussed and provided to staff Princess Bowen.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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 2
Document Has Been Signed on 06/10/2024 03:00 PM - It Cannot Be Edited


Created By: Melody Brown On 06/10/2024 at 02:29 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
, CA 92507

FACILITY NAME: BLU SKYYZ RESIDENTIAL CARE
FACILITY NUMBER: 365530011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/11/2024
Section Cited
CCR
80069(b)

1
2
3
4
5
6
7
80069 Client Medical Assessment (b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
LIcensee stated to obtain Client #1 Medical Assessment or submit proof of Medical Appointment to obtain C1 Medical Assessment to LPA brown on Plan of Correction (POC) due date.
Licensee stated to submit Signed Statement of Understanding on CCR 80069(b) to LPA Brown on POC due date.
8
9
10
11
12
13
14
Based on interview, observation and records review, the Licensee did not comply with the section cited above by not obtaining and keep on file documentation of the Client #1 (C1) medical assessment prior to accepting C1 at the facility on 03/29/2024 which poses immediate health, safety and personal rights risks to clients in care.
8
9
10
11
12
13
14
Type B
06/21/2024
Section Cited
CCR80068(a)

1
2
3
4
5
6
7
80068 Admission Agreements (a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated to complete an Admission Agreement for C1 and C1's Representative, if any and submit proof to LPA Brown on POC due date.
8
9
10
11
12
13
14
Based on interview, observation and records review, the Licensee did not comply with the section cited above by not completing an individual written admission agreement for Client #1 (C1) and the C1's authorized Representative which poses potential health, safety and personal rights risks to client in care.
8
9
10
11
12
13
14
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2