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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 11/30/2021
Date Signed: 11/30/2021 11:24:57 AM

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 MANORFACILITY NUMBER:
342701097
ADMINISTRATOR:RICHARDSON, SHERRYFACILITY TYPE:
740
ADDRESS:5510 SKY PARKWAYTELEPHONE:
(916) 422-5650
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:144CENSUS: 71DATE:
11/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sherry RichardsonTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct a case management visit due to the recent change of ownership. LPA Valerio was screened fro COVID-19 symptoms with temperature taken prior to being allowed entry into the facility. Front desk staff confirmed zero staff or residents have displayed any signs or symptoms of COVID-19 in the last 10 days.

LPA Valerio met with Administrator Sherry Richardson and explained the purpose of the visit. LPA toured the physical plant to ensure compliance with Title 22 regulations. The facility was observed to be clean with no sticky floors. Common areas were being utilized by residents while staff monitored the halls and assisted with residents. The facility has perishable foods for one week and non-perishable foods for two days along with an emergency supply of food. Kitchen staff were preparing lunch and wearing appropriate protective coverings. Common areas had hand sanitizer and house keeping was cleaning the rooms. LPA Valerio reviewed the facility roster, two random staff files, and two random resident files. All files were complete with necessary documentation with updated information.


Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left for Administrator Sherry Richardson.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
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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