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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 11/14/2025
Date Signed: 11/18/2025 03:31:03 PM

Document Has Been Signed on 11/18/2025 03:31 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: 84DATE:
11/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Susan McClureTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On November 14, 2025, at 10:15 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Susan McClure and explained the purpose of today's visit.

Administrator holds current certificate and expires in January 2026. The facility is licensed for 144 non-ambulatory residents. There are currently 84 residents who reside at this facility. The facility has an approved hospice waiver for ten.

The facility's last fire alarm system inspection was completed on April 11, 2025. The last fire testing and and maintenance inspection was on May 20, 2025. Last fire inspection report indicates fire sprinklers are not in good repair and water gong is in operable. The last fire drill documentation states March 10, 2025. The facility shall conduct a drill at least quarterly for each shift. LPA Martinez reviewed the inspection control plan and disaster preparedness plan. LPA Martinez reviewed food service consultation report. The last food service consultation was in December of 2019, and LPA Martinez was informed by S1 there is not a nutritionist, dietitian, or home economist available at the facility.

Continued...

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097
VISIT DATE: 11/14/2025
NARRATIVE
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LPA Martinez reviewed two medication administration records (MARs). Resident 1 (R1) was not maintained. R1's MAR was not signed on November 5th and 8th. R1's vitamin B-12 MAR entry does not reflect medication order. MAR entry for B-12 states 500 MG; the Medication Bottle states 1,000 MG; The medication order states 1,000 MG. R1's Donepezil HCL bottle label order was altered with a black marker. The Donepezil bottle states 10 MG and medication order states 5 MG. Additionally, there is no Donepezil split order documentation. R1's Ferrous sulfate 325 MG Tablet MAR entry does not reflect the medication bottle order.

LPA Martinez will return at a later date and time to complete 2025 annual inspection. The following deficiencies can be found on the D-Page: Fire Safety 87203, 1569.695 (c); Emergency Plans; and Incidental and Medical 87465(a)(6); Incidental and Medical 87465(h)(4). An exit interview was conducted and a copy of this 809 report, 809-D page, and appeals rights were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 11/18/2025 03:31 PM - It Cannot Be Edited


Created By: Avelina Martinez On 11/14/2025 at 02:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
Fire Safety 87203: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not ensure sprinkler system and water gong were in good repair which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2025
Plan of Correction
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Facility staff member agrees to email LPA Martinez fire safety plan, sprinkler system plan, and water gong repairs plan by POC date: 11/15/2025 by 5:00 PM.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2025 03:31 PM - It Cannot Be Edited


Created By: Avelina Martinez On 11/14/2025 at 02:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not ensure to complete quarterly fire drills which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2025
Plan of Correction
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Facility staff agrees to complete a fire drill at each shift by 11/15/2025. Facility staff agrees to email LPA Martinez fire drill log documentation by 11/15/2025 by 5:00 PM.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2025 03:31 PM - It Cannot Be Edited


Created By: Avelina Martinez On 11/14/2025 at 02:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not ensure to maintain a record of dosages of medications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2025
Plan of Correction
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Facility staff agrees to conduct an incidental and medical in-service training for all Medication Technicians by poc date 11/28/2025. Facility staff agrees to email LPA Martinez in-service training documents by 11/28/2025 by 5:00 PM.
Section Cited
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2025 03:31 PM - It Cannot Be Edited


Created By: Avelina Martinez On 11/14/2025 at 02:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(17)
87555(b)(17) General Food Service Requirements In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency, nature and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a interview record review, the licensee did not ensure regular food service consultations were conducted regularly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2025
Plan of Correction
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Facility staff agrees to conduct a food consultation with a qualified Nutritionist, Dietitian, or a Home Economist by POC date 12/05/2025 by 5:00 PM. Facility staff agrees to email Consultation report to LPA Martinez by POC date 12/05/2025 by 5:00 PM.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2025 03:31 PM - It Cannot Be Edited


Created By: Avelina Martinez On 11/14/2025 at 03:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
87465(h)(4) Incidental Medical and Dental Care: All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on [(observation) (interview) (record review)], the licensee did not ensure R1's medication bottle lable was not altered which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2025
Plan of Correction
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2
3
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Facility staff agrees to conduct an incidental and medical in-service training for all Medication Technicians by poc date 11/28/2025. Facility staff agrees to email LPA Martinez in-service training by 11/28/2025 by 5:00 PM.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2025


LIC809 (FAS) - (06/04)
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