342701097-11-8-2023-27-AS-TTRG-CX8UP9-20231103154510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 11/03/2023
Date Signed: 11/08/2023 02:17:16 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/08/2023 02:17 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:	SKYPARK MANOR		FACILITY NUMBER:	342701097
ADMINISTRATOR:	RICHARDSON, SHERRY		FACILITY TYPE:	740
ADDRESS:	5510 SKY PARKWAY		TELEPHONE:	(916) 422-5650
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	144	CENSUS: 84	DATE:	11/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sherry Richardson		TIME COMPLETED:	04:10 PM

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	This is an initial Required -1 Year visit. Due to technical difficulties the type of visit 'Case Management - Annual Continuation' was selected because a ‘Required - 1 Year’ option was not available. The inspection Care Tool was also unavailable during today’s inspection. On 11/3/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a Required – 1 Year annual inspection visit. LPA met with Administrator Sherry Richardson and explained the purpose of the visit. Administrator holds certification # 6024408740 and expires on 1/25/2025. The facility is licensed for 144 non-ambulatory, of which 10 may be bedridden. Approved hospice waiver for 10. There are 84 residents in care currently. LPA toured and inspected the physical plant with Assistant Administrator Susan McClure. LPA observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room was toured. Medication room was toured. Kitchen was toured for adequate food supplies and storage. A review of the facility perimeter fence, side gates, and exits was conducted. A review of the resident rooms was conducted. LPA observed the facility to be clean and in good repair. LPA observed required furniture and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. Report continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

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

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: 11/03/2023

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
26
27
28
29
30
31
32

The hot water temperature was measured at approximately 115.5 degrees Fahrenheit in rooms #136, 135, 120, 228, and 215. The temperature inside the facility measured at 72.0 degrees Fahrenheit. LPA observed centrally stored medications, toxins, and sharp knives kept locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. Proof of current liability insurance was observed.

LPA requested resident and staff files for review. LPA reviewed six (8) resident files and six (6) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

The following documents were obtained during today's visit:
LIC 308 Designation of Administrative Responsibility, Administrator Certificate, and Proof of Current Liability Insurance, LIC 500 Personnel Report and LIC 610 Emergency Disaster Plan.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2