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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 10/31/2022
Date Signed: 11/02/2022 09:58:08 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/02/2022 09:58 AM - 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 AC/SC, 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: 88DATE:
10/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:RICHARDSON, SHERRYTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Kesha Lewis and Albert Johnson arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA's were met by Staff member and Administrator joined 5 minutes later. LPA'S were screened upon entry for COVID precautions. LPA's explained the purpose of the visit to Administrator. Administrator's Certificate # 6024408740 Expires 01/25/2023.

LPA's and Administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 88 bed facility with a current census of eighty eight. There is entry door is leading to a hall way at the end of the hall in a check in desk to the left there is a hallway to the bedrooms and bathrooms, and an elevator to the second floor elevator permit expired 12/15/2021. The hallway has COVID precautions in place including social distancing noted. Chemicals and medications noted to be locked to residents in care.

Hot water temperature was measured at 106 F degrees Fahrenheit in downstairs bathroom sink, and 118.5 in upstairs resident bathroom sink room 233 which is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA's observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097
VISIT DATE: 10/31/2022
NARRATIVE
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LPA's observed the facility to have hand washing stations, COVID - 19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a COVID -19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA's observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings.

LPA's observed, fire extinguishers inspected on 10/20/2022 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution.

LPA reviewed five (5) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required.



LPA reviewed ten (10) resident's in memory care files and (5) resident 's in assisted living facility files, COVID-19 Plan, and survey binder. Five (5) of the memory care had out dated needs and services plans and 1 out of 10 had outdate 602. LPA's observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils.

LPA Lewis requested updated copies via email to LPA by November 11th 2022, of Infection control plan including Monkey pox and a copy of the surety bond. Kesha.Lewis@dss,ca,gov.

Exit interview held with staff and copies of reports left at conclusion of visit.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/02/2022 09:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2022
Section Cited

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Incidental Medical and Dental Care Services. When prescription medications must be destroyed, specific procedures must be followed and itemized records must be kept for a minimum of three years.
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This requirement is not met as evidenced by LPA'S observed medication in the med room refrigerator for R1 to be expired 07/2022. based on records review on at leat 5 days in October controlled medication was not singed for at end or beginning of shift. This poses a imitate risk to residents in care.
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store and dispense medication shall attend an in-service medication documentation training plan shall be submitted to Licensing by 11/01/2022.
Type A
11/01/2022
Section Cited

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Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually. This requirement was not met as evidenced by:
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LPAs observed during records review that R6 is diagnosed with dementia and didn't have an updated assessment. This poses a imitate 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.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097
VISIT DATE: 10/31/2022
NARRATIVE
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Based on records reviewed on at least 5 days controlled medications were not sinning for and end of shift and or start of shift. 10/5/2022, 10/06/2022, 10/08/2022, 10/10/2022.

Based on LPA'S observation of med room refrigerator expired eye drops were found for R1 expired, 07/2022. Medication for R1 was missing for 10/27/2022. R1 was in hospital at that time.

Based on information reviewed in R1's file, the facility failed to get treatment for R1 after notes from the FNP detailed a pressure injury that needed to be treated by home health. The facility did not get the order from a doctor to have the wound looked at. R1's left arm became swollen and was sent out to Mercy ER, R1 was sent back to the facility with no discharge papers and no new orders. The reason for the original ER visit on 10/13/2022 was for a soft tissue infection. No other information was available regarding location of the infection or follow-up treatment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/02/2022 09:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2022
Section Cited

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Care and supervision.
(f) Basic services shall at a minimum include:

(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
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This requirement is not met as evidenced by Based on records reviewed and interviews
conducted the Licensee was aware of R1's pressure injury on 10/7/2022. There was no follow-up for five days as a result, R1 was sent out to the ER on 10/13/22 and seen for a soft tissue infections and admitted to the hospital for 15 days and transported back to the facility without discharge papers. The facility is unaware of any treatment for the pressure injury that was noted on 10/7/2022. This poses an immediate health and safety risk to this residents.
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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.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5