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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700257
Report Date: 10/27/2021
Date Signed: 10/27/2021 03:53:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2021 and conducted by Evaluator Arlene D Garcia
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210921102551
FACILITY NAME:SKYE RESIDENTIALFACILITY NUMBER:
502700257
ADMINISTRATOR:SAUDIA WHITAKERFACILITY TYPE:
735
ADDRESS:3917 EAST ORANGEBURG AVENUETELEPHONE:
(209) 596-4168
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY:4CENSUS: 4DATE:
10/27/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Derek King, Administrator (AD)TIME COMPLETED:
01:03 PM
ALLEGATION(S):
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Staff did not properly report an incident involving a client while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to Skye Residential for the purpose of delivering the findings of the above allegation. LPA was greeted by Lillie King, Caregiver S1. LPA met with Derek King, Admiinistrator (AD) and advised the purpose of LPA's visit.

The initial 10 day Visit was conducted on 9/24/2021.

It was alleged that staff did not properly report an incident involving a client while in care.
During the course of the investigation, LPA interviewed staff. LPA toured facility. LPA reviewed resident and facility records. Records reviewed R1 was treated by a physician via telehealth and mobile xrays were conducted. AD confirmed the incident occurred on 6/23/21 and that AD did not know it needed to be reported to CCLD. AD stated AD was not aware incident needed to be reported as R1 did not sustain any fractures and had no change in medical condition.

Based on interviews and records reviewed, the allegation that staff did not properly report an incident involving a client while in care has been deemed SUBSTANTIATED.
This agency has investigated the allegation notice and has found the allegation to be substantiated meaning that there was a preponderance of evidence to prove the allegation was true as reported.

The following deficiency was cited per Title 22 Provision 6 of the CA Code of Regulations. An exit interview was conduct. A copy of this report along with appeal rights was provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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 27-AS-20210921102551
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SKYE RESIDENTIAL
FACILITY NUMBER: 502700257
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2021
Section Cited
CCR
80061(b)
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80061(b) Reporting Requirements. Upon the occurrence, of specified events, reports shall be made to the licensing agency within the agency's next working day.

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Administrator shall review reporting requirements under section cited and provide CCL with a written declaration stating that he/she has read and understands the Title 22 Regulations regarding reporting requirements and agrees to report as required in the future.
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This requirement is not met as evidenced by:
Based on record review and interview, the Licensee did not submit an incident report in a timely manner. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2