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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 08/18/2023
Date Signed: 08/18/2023 04:01:55 PM


Document Has Been Signed on 08/18/2023 04:01 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SKYPARK MANORFACILITY NUMBER:
342701097
ADMINISTRATOR:RICHARDSON, SHERRYFACILITY TYPE:
740
ADDRESS:5510 SKY PARKWAYTELEPHONE:
(916) 422-5650
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:144CENSUS: 85DATE:
08/18/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Rabindar SinghTIME COMPLETED:
04:15 PM
NARRATIVE
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On 08/18/2023 at 2:00 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to conduct a case management visit. LPA Lee met with Business Office Manager, Rabindar Signh and explained the purpose of the visit.

The purpose of today's visit, is in response to a learned deficiencies from a complaint investigation control number: 27-AS-20230802083802. During the complaint investigation on 08/04/2023 Resident #1 (R1) stated that the water was too hot in R1's room. LPA Lee measured the R1's sink water and it measured at 128.5*F. LPA Lee also measured the shower water and it measured at 129.0*F, which is not within the required regulations of 105 to 120 degrees Fahrenheit.

The following deficiency were observed and cited form California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of this LIC 809 report and appeal rights were given to Business Office Manager,Rabindar Signh
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
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 08/18/2023 04:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2023
Section Cited
CCR
87303(e)(2)

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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 was not met evidence by:
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Licensee agrees to adjust the hot water temperature and email LPA Lee (pang.lee@dss.ca.gov) a picture and a video of the new water temperature by 08/23/2023 by 5:00 PM by end of day.
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Based on observation and inspection the resident bathroom sink water temperature measured at 128.5*. Licensee did not ensue the water is within regulations which posed 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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
LIC809 (FAS) - (06/04)
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