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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 03/17/2022
Date Signed: 03/17/2022 03:59:48 PM


Document Has Been Signed on 03/17/2022 03:59 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
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: 68DATE:
03/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Susan McclureTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady and Christina Valerio arrived at the facility unannounced to conduct a case management visit due to the recent change of ownership. LPAs were screened for 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.

LPAs met with Susan McClure Assistant Administrator and explained the purpose of the visit. LPAs toured the physical plant to ensure compliance with Title 22 regulations. The facility was observed to be clean. 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. All staff were wearing protective N95 respirators. LPAs reviewed the facility roster, two random staff files, and two random resident files. All files were complete with necessary documentation with updated information.

The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed the fire extinguisher(s) expiration date 4/22/2023, smoke detectors, carbon monoxide detectors and pull alarm system. Facility has central heating and air.



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 Susan Mcclure. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022
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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