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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 03/14/2024
Date Signed: 03/14/2024 04:04:49 PM


Document Has Been Signed on 03/14/2024 04:04 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: 71DATE:
03/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Erisa JonathanTIME COMPLETED:
04:30 PM
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On 3/14/24, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced case management visit to follow up on the death report of a resident. LPA met with Medication Technician Erisa Jonathan and explained the purpose of today’s visit.

The purpose of this case management visit is to follow up on a death report the Department received on 3/8/2024. According to the report, caregiver discovered resident (R1) was on the floor when doing rounds at 6:14am on 3/5/2024. Resident reported to staff that they were having difficulty breathing. 9-1-1 was called and upon their arrival resident has stopped responding. Paramedics performed CPR but when resident didn't respond they pronounced resident dead at 7:14am. LPA Truong conducted file review for former resident and obtained resident’s pertinent documents. LPA could not interview staff who first discovered R1 as they were not present at the time of visit. Facility administrator and assistant administrator have left for the day; therefore, no additional information was gathered.

Per the California Code of Regulations, Title 22, no deficiencies were cited during this visit. LPA will return at a later date to complete the investigation.

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: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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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