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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700257
Report Date: 09/24/2021
Date Signed: 09/24/2021 06:11:05 PM

Document Has Been Signed on 09/24/2021 06:11 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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:
09/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Derek King, AdmiinistratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst, LPA Arlene Garcia visited the facility today to open a complaint investigation 27-AS-20210921102551. LPA was greeted by Lillie King, Caregiver S1. LPA met with Derek King, Administrator and advised the purpose of LPA's visit.

LPA observed toxins on the counter in the kitchen area. Caregiver stated they have kept them out since the pandemic as facility was constantly disinfecting areas. LPA advised caregiver that all toxins need to be locked and out of reach of the clients.

Deficiencies were cited on today's date. Exit interview conducted. Appeal rights discussed and a copy given to the Administrator. A copy of this report was given to the Administrator.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
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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Document Has Been Signed on 09/24/2021 06:11 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 09/24/2021 at 01:30 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SKYE RESIDENTIAL
FACILITY NUMBER: 502700257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2021
Section Cited
CCR
80087(g)

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Buildings and Grounds. Disinfectants, cleaning solutions, poisons, and other items that could pose a danger to clients shall be inaccessible.
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Caregiver immediately locked toxins when LPA was in facility. Administrator will conduct an in staff training wtih all staff and submit proof of training and acknowledgment of undertsanding of regulation by POC date.
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This was not met as evidence by LPA observed disinfectants and toxins unlocked in the kitchen area accessible to clients. This poses an immediate risk to clients 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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2021


LIC809 (FAS) - (06/04)
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