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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701097
Report Date: 11/26/2025
Date Signed: 12/01/2025 09:28:47 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/23/2025 and conducted by Evaluator Cynthia Tamayo
COMPLAINT CONTROL NUMBER: 27-AS-20251123203239
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: 74DATE:
11/26/2025
UNANNOUNCEDTIME BEGAN:
11:59 AM
MET WITH:Sherry RichardsonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not ensure resident's medication was provided.
INVESTIGATION FINDINGS:
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On 11/26/25, Licensing Program Analyst (LPA) Cynthia Tamayo arrived unannounced to conduct a follow-up investigation into an allegation noted above. LPA met with Susan McClure, Assistant Administrator (S2) and stated the purpose of this visit. Administrator, Sherry Richardson (S1) arrived later on during this visit.

LPA requested the following records for review:
• LIC 500
• LIC 9020

And the following records for R1-R4:
• LIC 602
• Appraisal
• Medication list
• November SIRs and discharge documents
•MARs
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20251123203239
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/26/2025
NARRATIVE
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It was alleged that staff did not ensure resident's medication was provided, the investigation into the above allegation consisted of interviews and record reviews. LPA conducted an interview with staff S1-S3. Record review reveal that R3 is prescribed psychotropic medications due to their mental health; Invega Sistenna (234 mg/1.5 ml) is prescribed to be injected intramuscularly every 28 days. S3 stated there was a delay on the pharmacy delivering the medications to the facility. Daily notes indicate S3 contacted the pharmacy the week of 10/27 and 11/5/25 in regard to requesting the medication for R3 be delivered. S3 stated R3 was supposed to get the shot on 11/3/25, however they did not received the Invega shot until 11/7/25.S3 stated they forgot to log it on the Medication Administration Record (MAR) and there is no record that R3 received the injection in November 2025. Per S3, R3 has not missed the injection in the past, aside from the month of June where there was a delay in medication, in which R3 refused the injection on 6/16/25 and it was given on 6/17/25. Based on interviews and observations of the LPA and review of records the allegation, staff did not ensure resident's medication was provided, is substantiated.

As a result, the allegations above are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted S1-S3 and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20251123203239
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility....
(4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by:
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By POC due date, licensee will submit of review and understating of Title 22 regulation: 87465 Incidental Medical and Dental Care in addition to providing quality assurance for MARs on a weekly basis.
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Facility staff did not providescheduleded medication to resident 3 (R3) on 11/3/25. S3 stated medication was administered 11/7/25, however it was not recorded on the MAR. This poses an immediate/potential health risk to residents in care.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Cynthia Tamayo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3