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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 12/29/2025
Date Signed: 12/29/2025 05:29:18 PM

Document Has Been Signed on 12/29/2025 05:29 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: 74DATE:
12/29/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Susan McClureTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
NARRATIVE
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On 12/29/25, Licensing Program Analyst (LPAs) Cynthia Tamayo made an unannounced case management visit to this facility to conduct a case management visit. LPA met with Susan McClure (S2), Dietary Manager and assistant administrator and explained the purpose of today's visit. Administrator, Sherry Richardson (S1) and Rabindar Singh (S3). Current administrator, Sherry Richardson (S1) was not present during this visit.

LPA discussed the plan of correction deficiencies cited 12/18/25:
-87405 Administrator - Qualifications and Duties (a); S2 stated an updated LIC 610 will be emailed to LPA by end of day 12/29/25. The administrator will be changed to S3, The request will be submitted to licensing by 12/30/25.
-87203 Fire Safety has been cleared.
-S2 stated the patio repairs are completed and ready for re-inspection from code enforcement. the roof repair is expected to start in April 2026 and no contract has been completed as of this date. The roof repair will consist of re-roofing and not re-patching.

LPA followed up on incident report received by the Regional Office on 12/19/25. R1 had an unwitnessed fall that occurred on 12/17/25. S2 stated that staff reviewed video footage and saw that dementia resident 2 (R2) pushed resident 1 (R1) due to R1 trying to enter their room. S2 stated R1 was sent out to the emergency room and is still in the hospital and it seems like they have a fracture on hip. S2 stated an amended incident report was sent to regional office on 12/29/25. The incident was unintentional Reporting requirements were reviewed.

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: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2025
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 12/29/2025 05:29 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 12/29/2025 at 12:54 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: 12/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2026
Section Cited
CCR
87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall ... (2) ... be accorded safe, healthful and comfortable accommodations ... This requirement was not met as evidenced by record review and
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By POC due date, facility staff will submit a plan to ensure there is adequate care and supervison for all resdients in addtion to a plan to ensure preventative measures are being taken for individuals with dementia including having an updated physician evaluations and reappraisals
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interviews in which it was learned that dementia resident, R1, has often tried to enter other resident rooms. On 12/17/2025, resident 2, R2, pushed R1 when they attempted to go into R2's room. Per staff interviews, R1 has been in the hospital for 10 days and has a bone fracture. This poses an immediate/potential health and safety risk to residents in care.
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 are done each time there is a change in baseline for any resident. Moreover, facility staff will ensure all staff have the required dementia , care and supervision, and reporting requirments, trainings.

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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:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2025


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: 12/29/2025
NARRATIVE
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Three staff interviews corroborate that at the same time as the incident, there was a care staff Christmas party on 12/17/25 happening around 12:30PM in which there should have been some care staff supervised the floor. The administrator nor S2 were present during this incident. S3 stated they were at the facility but did not assist with this incident. S4 reported that R1 stated "someone pushed me". The Medication Technician was called by S4 and R1 was transported to the hospital. Three staff reported R1 often knocks on other resident doors thinking it was their room. R2's care plan stated supervision and re-direction shall be implemented. On 12/29/25, S3 stated R1 was being evaluated by their physician for medication adjustment due to their diagnosis and behaviors.

LPA went on a facility tour with S3 at around 2:00 PM. LPA observed there were ceiling panels pieces that were damaged from the roof leaks, there is water dripping from three new missing panels/panel pieces on the second floor hallway, in which there are trash bins placed below to catch the water. S2 stated no residents have fallen due to wet floor and maintenance is periodically checking for new leaks and ensuring there is no fall hazards. LPA is requested for facility to have the building evaluated to ensure it is safe and habitable for residents. At this time, the roofing is not able to be repaired until spring of 2026 and it is uncertain if residents are being exposed to mold and asbestos particles as a result to the ongoing water damage. LPA observed some trash bins have accumulated over a gallons worth of water. LPA provided guidance around ensuring preventative measures are being taken, including cleaning up water leaking onto the floor and bins catching water leaks are being emptied out at least twice per day.

LPA requested delayed egress fire clearance verification, to be submitted to licensing by 1/2/25.
There is one deficiency cited during this case management visit. An exit interview was conducted with the Licensee, and a copy of these LIC 809 reports 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: 12/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025
LIC809 (FAS) - (06/04)
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