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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 12/12/2024
Date Signed: 12/12/2024 03:54:47 PM

Document Has Been Signed on 12/12/2024 03:54 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: 89DATE:
12/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:16 PM
MET WITH:Susan McClureTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 12/12/2024, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit regarding a death incident. LPA met with the Assistant Administrator Susan McClure and stated the purpose of this visit.

The Regional Office (RO) received a death report for resident (R1), who was reported to have passed away on 10/15/2024. Facility staff (S1) reported that R1 was found unresponsive on the floor of their room with no pulse. CPR was provided until paramedics arrived and continued CPR until R1 was pronounced dead at 8:42 AM. Prior to being found on the floor, R1 had been sitting in their chair.

An investigation was conducted by the Department, focusing on the review of the death certificate. The death certificate listed cardiac arrest as the immediate cause of death, with the following contributing health conditions: C1 and C2. It was noted that no autopsy or biopsy was performed. The investigation concluded that there were no signs or indicators suggesting that R1's death was questionable.

Per the California Code of Regulations, Title 22, no deficiencies were cited during this visit.

An exit interview was held with Susan McClure, and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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