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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 09/02/2026
Date Signed: 09/02/2026 03:59:48 PM

Document Has Been Signed on 09/02/2026 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SKYPARK MANORFACILITY NUMBER:
342701097
ADMINISTRATOR/
DIRECTOR:		RABINDAR SINGHFACILITY TYPE:
740
ADDRESS:5510 SKY PARKWAYTELEPHONE:
(916) 422-5650
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY: 144CENSUS: 69DATE:
09/02/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator- Rabinder SinghTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On September 02, 2026, at 1:30 PM, Licensing Program Analyst (LPA) Sulma Lopez and Licensing Program Manager (LPM) Arielle Pascua arrived unannounced at the facility to conduct a quarterly inspection due to non-compliance conference held on 04/30/2026. LPA and LPM met with Administrator (A1) Rabinder Singh and explained the purpose of today's visit.

At 1:15 PM LPA and LPM toured the 1st and 2nd floor of the facility with A1. LPA observed several areas of the flooring were raised and bubbling, making an uneven walking surface. The elevators were serviced annually on January 31, 2026.
Resident bedrooms were furnished with beds, dressers, and P-TAC air conditioning units in each room. LPA observed Resident 1's (R1) room to have a strong urine smell.LPA observed that the room is furnished with carpet flooring. A1 asked Staff 1 (S1) to shampoo the carpet thoroughly after the smell was identified. LPM Pascua asked what types of support the facility conducts to ensure that the resident's incontinence needs are being met. A1 stated that the resident does not utilize incontinence briefs, staff remind him to toilet independently, but it is difficult because he has dementia. A review of R1's assessment was conducted, it was revealed the resident is incontinent with their bladder and bowel. It was learned that the facility is responsible to ensure the resident is prompted to use the restroom every 2 hours or as needed. In addition, a review of the facilities procedures for daily cleaning states that the facility staff should ensure the resident bedrooms are odor free.

The facility hallways were observed to be free of clutter and the walkways were free of obstructiosn. The facility temperature was 75 degrees. LPA observed the ceiling tiles from a previous leak were still present in the facility. The tiles have been patched to fill in gaps and LPA observed water damage stains present.
Continued on LIC 809-C.
Arielle Pascua
Sulma Lopez
DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2026
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: 09/02/2026
NARRATIVE
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LPA and LPM toured the upstairs activity room which was under renovation from the previous leak. It was learned that the roof has been repaired and additional work is being completed in the activity room.
LPA and LPM identified 2 stairways at the end of each hallway equipped with an emergency chair.

The exterior of facility was clear of debris. All outdoor passageways were kept free from obstruction.

LPA and LPM toured the dining area and facility kitchen. The areas were observed to be clean, free of odors, and free of hazards. The dining room area contained enough seating for the current census. A meal menu was posted in the facility kitchen. LPA observed food supplies included 2 days of perishables and at least 7 days of non-perishable food items.

At 2:30 PM, LPA and LPM conducted records review of the facility's Policy and Procedures Manual, Fire Drill Logs, Resident Records, and Emergency Disaster Plan. The last fire drill was conducted on August 6, 2026. It was learned that since April 30, 2026, the facility has changed and implemented several policies and procedures pertaining to their maintenance and operation and emergency disaster planning, however the facility has not reviewed their Emergency Disaster Plan since December 29, 2025 including but not limited to instructions on how to utilize emergency evacuation chairs.

Based on the observations made during this visit, the following deficiencies are being cited during this visit. An exit interview, appeals rights, and a copy of this report was provided to the facility at the end of this visit.
NAME OF LICENSING PROGRAM MANAGER: Arielle Pascua
NAME OF LICENSING PROGRAM ANALYST: Sulma Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/02/2026 03:59 PM - It Cannot Be Edited


Created By: Sulma Lopez On 09/02/2026 at 03:23 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: 09/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2026
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation (a)- The facility shall be clean, safe, sanitary and in good repair at all times.
The requirement is not met as evidenced by:
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The facility agrees to create a repair plan detailing the scope of the repairs and plan to minimize disruptions to residents in care. The facility agrees to send the finalized plan to the Department by Friday October 2, 2026 by 5PM.
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Based on observation, interviews, and records review, the licensee did not ensure that the facility floors did not have bubbling and lifting, making an uneven walking surface which poses a potential health, safety, or personal rights risk to residents in care.
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Type B
09/18/2026
Section Cited
CCR87625(b)(3)

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87625 Managed Incontinence- (b)... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
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Facility agrees to conduct an in service training with care staff on proper incontinence care procedures. The facility agrees to email a copy of the in service training to the Department by Friday September 18, 2026 by 5:00pm.
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Based on observation, interviews, and records review, the licensee did not ensure that R1's room was free of odor from incontinence which poses a potential health, safety, or personal rights 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.
Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:
Sulma Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/02/2026 03:59 PM - It Cannot Be Edited


Created By: Sulma Lopez On 09/02/2026 at 03:30 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: 09/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2026
Section Cited
HSC
1569.695(d)

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1569.695 Emergency Plans- (d) A facility shall review the plan annually and make updates as necessary... The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated... This requirement is not met as evidenced by:
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The facility agrees to review and update the Emergency Disaster Plan. The facilty agrees to send a signed copy of the updated plan to the Department via email by Friday, September, 18, 2026 by 5pm.
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Based on observation, interviews, and records review, the licensee did not update and sign the Emergency Disaster Plan following the implementation of new procedures after April 30, 2026 which poses a health, safety, or personal rights risk for 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.
Arielle Pascua
NAME OF LICENSING PROGRAM MANAGER:
Sulma Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
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