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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 01/09/2024
Date Signed: 01/09/2024 12:50:45 PM


Document Has Been Signed on 01/09/2024 12:50 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:RICHARDSON, SHERRYFACILITY TYPE:
740
ADDRESS:5510 SKY PARKWAYTELEPHONE:
(916) 422-5650
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:144CENSUS: 77DATE:
01/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Susan McClureTIME COMPLETED:
01:30 PM
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On 1/9/24 at 11:00am Licensing Program Analyst (LPA) Tung Truong conducted an unannounced case management inspection to ensure the health and safety of residents and address additional questions regarding the death of R1. LPA met with Assistant Administrator Susan McClure and explained the purpose of today’s visit.

The death report indicated that, on 1/4/2024, resident (R1) was discovered behind the facility building hanging from a tree at approximately 3:50pm. A camera footage revealed that R1 secured a rope over a tree branch, climbed up on his walker and then pushed it way and hung himself. LPA Truong conducted file review for former resident and conducted interviews with staff members to get additional information regarding the former resident and to obtain additional information leading up to his death and the actions of the facility immediately after resident was found unresponsive. LPA could not interview staff who first discovered R1 as she is not present at the time of inspection.

Based on the interviews, information gathered, and documentation reviewed there were no deficiencies assessed at the time of inspection.

Exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
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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