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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 10/23/2024
Date Signed: 10/23/2024 04:50:30 PM

Document Has Been Signed on 10/23/2024 04:50 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SKYPARK MANORFACILITY NUMBER:
342701097
ADMINISTRATOR/
DIRECTOR:		RICHARDSON, SHERRYFACILITY TYPE:
740
ADDRESS:5510 SKY PARKWAYTELEPHONE:
(916) 422-5650
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 144CENSUS: DATE:
10/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Susan McClureTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 10/23/24, at 10:15am, Licensing Program Analyst (LPA) Arvin Villanueva, arrived to this facility unannounced to conduct their required annual inspection visit. LPA met with Susan McClure, Assistant Administrator (AD), and explained the purpose of the visit. The facility currently has an approval to retain/accept 144 non-ambulatory residents, 10 of which may be bedridden residents.

LPA and AD toured the facility to ensure compliance of Title 22 regulation. Facility is a two-story building located in a residential neighborhood. LPA observed the first floor, second floor, the activity room, dining room, elevator, stairwells and random resident apartments/units. Facility has a 144-resident capacity for both assisted living and memory care residents. Memory care area is located on the first floor. Facility has one elevator and currently operable and in good repair during this visit. Facility has 3 stairwells. Each stairwell were equipped with evacuation sling located in the second floor for emergency use. 1 of 3 stairwell is equipped with evacuation chair located at the first floor of the stairwell. LPA observed 5 of 6 fire extinguishers to be expired and were last serviced on 10/4/23.

The resident apartments/units are spacious enough to accommodate the residents' furnishings. 6 of 6 resident apartments/units were observed. Each resident apartment/unit is equipped with resident bathroom, small refrigerator, and air conditioning/heating unit. The air conditioning/heating unit are operated by the residents. Each apartment/unit is equipped with sprinkler system. 6 of 6 resident bathrooms were observed. Water temperature in 6 randomly selected bathrooms (in a resident apartment/units) were measured at between 110 and 114 degrees F. In one resident bathroom (R1), their hot water sink faucet did not have hot water. In one resident bathroom, it did not have a grab bar by the toilet for non-ambulatory resident. Technical Advisory (TA) was provided to AD to clean out cobwebs observed at the ceiling in resident apartment/units. TA was also provided for facility to conduct minor repairs such as drawer in disrepair observed in one resident apartment/unit and medicine cabinet in disrepair in another resident apartment/unit. Photos were taken for reference.
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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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 10/23/2024 04:50 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 10/23/2024 at 02:59 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. 5 out of 6 fire extinguishers (including one in the kitchen) were observed to be out of compliance. They were last serviced 10/4/23 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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Licensee to submit a statement of understanding of the regulation cited and submit statement to the Department by POC due date.
Licensee to obtain or service all fire extinguishers. Licensee to send notification and proof that a fire extinguisher was obtained or serviced by 10/30/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 10/23/2024 04:50 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 10/23/2024 at 03:17 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. During inspection of resident apartments/units, one resident (R1) did not have hot water in their bathroom sink faucet (no water came out when turned on) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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Licensee to submit a statement of understading of the regulation cited above. Licensee to submit statement to the Department by POC due date.
Licensee to ensure hot water is provided to all residents at all times.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097
VISIT DATE: 10/23/2024
NARRATIVE
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LPA observed a shaded area in the courtyard with tables and chairs. Additionally the outdoor area for activities is secure for dementia residents. Outdoor passageways, walkways, driveways, and steps are free from obstructions and hazards. The facility does not have bodies of water at this time.

LPA and AD inspected the kitchen and main dining area. Kitchen was observed to be clean and sanitized. Food were observed to be properly stored during this visit. Facility kitchen has 5 freezers, 2 refrigerators and 2 pantries for dry and canned foods. Main dining room was observed to be clean and sanitized. This is also where the fireplace is located and it was observed to be enclosed.
The medication room is located in the first floor and medications were observed to be properly stored, locked and inaccessible to residents in care.

LPA conducted file review of 6 resident files and 8 staff files. LPA was unable to review facility's infection control plan and Emergency Procedure Plan at this time. Per interview with the Business Office Manager, they have not conducted quarterly drills since COVID.

The following deficiency was observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Failure to correct the deficiency may result in civil penalties.

An exit interview was conducted with AD, and a copy of this report and appeal rights were provided.








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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 10/23/2024 04:50 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 10/23/2024 at 03:58 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview the licensee did not comply with the section cited above. According to interview with staff, they have not conducted their quarterly drill since COVID which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2024
Plan of Correction
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Licensee to submit a statement of understanding of the regulation cited above; statement to be submitted to the Department by POC due date.
Per discussion with AD, staff will start conducting quarterly drills moving forward.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
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