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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 12/18/2025
Date Signed: 12/18/2025 06:23:34 PM

Document Has Been Signed on 12/18/2025 06:23 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: 79DATE:
12/18/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Susan McClureTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 12/18/2025, Licensing Program Analysts (LPAs) Cynthia Tamayo and Avelina Martinez made an unannounced case management visit to this facility to conduct a case management visit. LPAs met with Susan McClure (S2), Dietary Manager and assistant administrator and explained the purpose of today's visit. Administrator, Sherry Richardson (S1), was not present during this visit.

LPAs discussed the plan of correction deficiencies cited 11/14-19/25 and requested an update on the following : 1. Maintenance and Operation 87303 (a): The building roof and resident exterior patio were not in good repair. The exterior resident back courtyard patio is under construction and closed to residents in care. Residents use the covered side patio area at this time.
Plan update: Code enforcement documentation shows that the facility was found to be in violation of code enforcement on 8/6/24, in which repairs were initiated by the facility. Code enforcement came back out to the facility on 10/15/24, in which they deemed the repair work was not done correctly by the contractor that was hired; the facility initiated a new contractor to complete the violation corrections and is in process to be completed this month. The construction crew received approval to pour the cement the week of 12/8/25 and it has been curing in the patio area. LPAs observed construction workers working on the patio area during this visit. Sacramento county inspector is coming out tomorrow, 12/18/25. S2 will send Sacramento County inspector’s contact information to LPAs. Sacramento code enforcement confirmed that the facility obtained a permit earlier this year. S2 stated code enforcement has not been back out in 2025 and the reason for delay is due to clarification and communication, as staff were not able to get a hold of permits and planning department.

CONTINUED ON 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2025
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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Document Has Been Signed on 12/18/2025 06:23 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 12/18/2025 at 11:13 AM
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: 12/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2025
Section Cited
CCR
87203

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87203 Fire Safety. 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 was not met as evidenced by the light fixture in the fire exit stairwell
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By POC due date, facility will submit verification fire exit stairwell light fixture is in good repair. LPA observed S2 request maintence person repair the light during this visit.
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was not in good repair, which poses a health a health and safety risk to residents in care
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Type B
12/22/2025
Section Cited
CCR87405(a)

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87405 Administrator - Qualifications and Duties (a) ...The administrator shall have sufficient freedom from other responsibilities ... on the premises a sufficient number of hours ... coverage by a designated substitute ... qualifications adequate to be responsible and accountable for management and

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By POC due date, licensee(s) and administrator(s) will submit a plan to remediate mold, aspestos, and pending code enforcement violations as safely and efficiently as possible. Additionally, a written safety and relocation plan will be submitted in regards to the unresolved roofing leaks which may be impacted
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administration. Based on observation, interview, and record review, the administrator did not ensure enough oversight to ensure the building's was kept safe and free from to hazardous materials which poses a potential health, safety rights risk to persons in care.
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by upcoming rainy days. Facility shall also submit a update to Community Care Licensing on a weekly basis from 12/26/25 - 6/26/25.
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:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2025


LIC809 (FAS) - (06/04)
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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: 12/18/2025
NARRATIVE
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2. On 11/19/25, LPA Martinez observed there was mold and leaks in two vacant resident bedrooms on the second floor. Remediation quotes from a third party company confirmed 6 out of 6 bedrooms tested positive for mold and asbestos. LPAs spoke with S2 via phone call during this visit in which they stated they will put a plan in place to test additional rooms throughout the facility for asbestos and mold as well. LPAs informed staff that the entire facility including all resident rooms, common areas, and exteriors and facility staff must be safe for residents and staff. Administrator will also ensure precautions will be put in place to ensure safe remediation is completed.
Roof: Due to mold and asbestos needing to be addressed first in addition to rainy conditions, the roofing repairs are not able to start until Spring 2026. Documentation of quote from one roofing company states “this application can only be done between April and September with adequate outside temperatures per manufactures instructions”.

During a facility tour with S2, LPAs observed there was water damage such as warping, bubbling, and discoloration on several hallway ceiling panels on the both floors of the facility. LPA also observed there was water leaking from a ceiling panel on the second floor near in room 219 and 220, in which trash bin was placed underneath the hole in the ceiling hole to collect the water dripping from the ceiling panel.

3. Fire Safety 87203: The facility's last fire alarm system inspection was completed on April 11, 2025. The last fire testing and maintenance inspection was on May 20, 2025. Sprinkler system and water gong were not in good repair which. S2 stated the facilities sprinkler system plan, and water gong repairs plan update: Fire Marshall, came to the facility on 11/18/25 and the documentation was received during this visit. Sprinklers were added, gongs were repaired, and fire alarms pull boxes were inspected. POC was cleared.

4. HSC 1569.695(c): quarterly fire drills were not being completed by facility staff POC cleared.
LPA observed the light fixture in the fire exit stairwell was non- operational during this visit. S2 had maintenance replace the light bulb of the stairwell during this visit.

5. Incidental and Medical 87465(a)(6) (6) facility did not maintain an accurate record of dosages of medications. POC cleared and staff agrees to continue maintain accurate MAR.
CONTINUED ON 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC809 (FAS) - (06/04)
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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: 12/18/2025
NARRATIVE
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6. General Food Service Requirements 87555(b)(17): Per food service consultation report, the last food service consultation was in December of 2019. Additionally, there is not a nutritionist, dietitian, or home economist available at the facility. Plan update: Qualified Nutritionist, Dietitian, or a Home Economist is scheduled to conduct audits in January 2025, and facility will submit findings to Licensing upon completion.

7. Incidental Medical and Dental Care: 87465(h)(4): Due to the alteration of a residents \ medication bottle label. Plan update: POC cleared, and facility agrees to not make any alteration of a residents medication bottle labels.

8. 87411(c)(1) Personnel Requirements – [ [2] out of [8] staff did not have a current first aid certificate
Plan update: POC was cleared and facility staff will ensure staff have a current first aid certificate.

9.P&I financial ledgers. Current surety bond amount is $5,000 via CAN Surety. Business office manager, Rabinder Singh (S3) stated residents PNI is deposited into a facility bank account designated for residents' money and all payees have designated payees. S3 stated Facility will Bank information to LPA by 12/22/25. Facility staff will review 87217 Safeguards for Resident Cash, Personal Property, and Valuables.

10. Facility sketch that includes camera locations will be submitted by 12/22/2025

11. Administrator oversight: Per LIC 500, Administer Sherry Richardson is scheduled at this facility 4 days per week from 7:00-17:00 however their schedule is variable and the LIC 500 is not accurate at this time. S1 holds current certificate #7007545740 that is valid thru 01/25/2027. S2 hold administrator certificate #7007207740 which expires12/28/2026. S1 stated they are spending most of their time overseeing Country Place Assisted Living – 075601547 in Antioch and S2 is "like the main administrator" for the most part. S2 stated the licensee/owner of the building has been informed of the conditions of the building. S3 assists with administrator duties. Med techs act as leads in case of an emergency. An updated LIC 500 and LIC 308 will be submitted to LPA by 12/22/25. S1 stated maintenance workers are scheduled to be present at the facility next week. LPAs discussed the importance that a qualified administrator is present next week to ensure there is oversight over the roof leaking issues during the upcoming rainy days.

12. LPAs advised S2 on ensuring the elevator certificate is renewed expiration date: January 8th, 2026.

CONTINUED on 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC809 (FAS) - (06/04)
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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: 12/18/2025
NARRATIVE
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13. Emergency Safety Plan: In the event residents need to be relocated, an updated safety plan shall be in place. Facility staff agree to submit written emergency/ safety plan update by 12/22/25. Licensee shall be included in the development of this plan.


As a result of this visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with S2 and a copy of these LIC 809 reports, LIC 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: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC809 (FAS) - (06/04)
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