342701097-11-2-2021-27-AS-CVAO-C8DPCA-20211102111136

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 11/02/2021
Date Signed: 11/02/2021 11:11:52 AM

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:	SKYPARK MANOR		FACILITY NUMBER:	342701097
ADMINISTRATOR:	SHERRY RICHARDSON		FACILITY TYPE:	740
ADDRESS:	5510 SKY PARKWAY		TELEPHONE:	(916) 422-5650
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	144	CENSUS: 71	DATE:	11/02/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Sherry Richardson		TIME COMPLETED:	11:22 AM

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	Licensing Program Analyst (LPA) Christina Valerio arrived at the facility to conduct an announced pre-licensing visit. LPA Valerio introduced herself and discussed the elements of the pre-licensing visit with Administrator Sherry Richardson. LPA Valerio was screened for COVID-19 symptoms and temperature taken prior to being allowed entry into the facility. Facility staff confirmed no resident or staff have been observed to have any signs or symptoms of covid in the last 10 days. The facility has a fire clearance for 134 non-ambulatory residents and 10 bedridden residents. The facility has an approved hospice waiver on file. Observed there are 71 residents in care. The facility has an approved LIC 808 mitigation plan on file and uploaded into FAS. LPA toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. The facility has 4 bedroom wings, 1 large dining room, 1 assisted dinning room, 1 commercial kitchen area, laundry room, 2 activity rooms, medication room, storage room, and exterior area. The facility has a secured outside area large enough for residents to take walks and have outdoor visits. LPA observed the area where the staff and resident files will be locked and readily available for review. Files were organized and had necessary documents. Emergency disaster plan and necessary signage posted and available. Facility has over a 30-day supply of face shields, gowns, N95s, surgical masks, hand sanitizers, and sanitizing wipes located in the storage room. First aid kits and emergency supply of food were observed to be fully stocked. LPA observed no obstruction of emergency exits inside or outside of facility. Continues on LIC 809-C... Page 1 of 2

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SKYPARK MANOR	FACILITY NUMBER: 342701097
	VISIT DATE: 11/02/2021

NARRATIVE

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Continues from LIC 809...

LPA Valerio observed the commercial kitchen area, dining area, 8 resident bedrooms and bathrooms, storage areas, medication room, and office areas. The kitchen was clean and organized. LPA observed area where food supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days will be maintained on the premises.The pantry space was stocked with food items, which were labeled and dated. The facility has an emergency supply of food available for 144 residents. Resident bedrooms observed to have necessary furniture. Resident bedrooms are furnished with a bed, chair, night stand, personal dresser, and extra closet space. Resident bathrooms observed to have non-skid mats, soap, paper towels, hand sanitizers, and garbage cans. Resident bedrooms were clean and did not have an odor. All emergency exits have appropriate signage. Cleaning supplies were secured and locked in the storage room. Smoke detectors and carbon monoxide detectors were noted and functioning properly. Hot water temperature in resident's bathroom measured at 109.1*F , 112.3*F, 110.4*F, 111.7*F, 110.2*F, 112.5*F, 109.6*F, and 112.4*F in 8 bathrooms, which is within regulatory range of 105 *F and 120 *F.

LPA Valerio observed multiple fire extinguishers placed throughout the facility. Fire extinguishers were up to date with last check on 09/23/2021.

Pre-Licensing is complete and this facility has no deficiencies. A Component III was completed at this time with the Administrator Sherry Richardson. Administrator had no further questions. Exit interview held, and a copy of the report was given. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC809 (FAS) - (06/04)

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