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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 09/27/2022
Date Signed: 09/27/2022 02:39:52 PM


Document Has Been Signed on 09/27/2022 02:39 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: 87DATE:
09/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Sherry RichardsonTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced regarding the incident report dated 9/19/2022 submitted to the Department. LPA Ivey Canady met with Administrator Sherry Richardson and explained the purpose of today's visit.

On 09/19/2022, an incident occurred at the facility. There was a resident to resident altercation that resulted in R1 hitting R2 with a can of soda in the mouth. This action resulted in R2 sustaining an injury to the mouth to include bleeding and a swollen lip. According to staff interviews and facility records, staff immediately called 911. The licensee/administrator informed the responsible party and Community Care Licensing within hours of the incident.

R2 refused medical assistance of any kind when the police, medics and fire department arrived. LPA Ivey Canady inquired the status of the injured resident and administrator reports R2 is fine and no longer injured. LPA Ivey Canady interviewed R2 and observed no current injury in the mouth area. R2 stated there is no injury. Since the incident, there has been no additional occurrences regarding R1 and R2.

Administrator stated residents are never left unattended for more than 5 minute intervals and residents are always walking the halls and visible to staff during the day.

LPA Ivey Canady requested and reviewed resident files of R1 and R2. There are no 1:1 designations for either resident.


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 given to Administrator Sherry Richardson.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
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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