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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 11/07/2022
Date Signed: 11/07/2022 01:23:05 PM


Document Has Been Signed on 11/07/2022 01:23 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:
11/07/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sherry RichardsonTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced regarding health check for Resident 1 (R1). LPA Ivey Canady met with Administrator Sherry Richardson and explained the purpose of today's visit.

LPA Jamie Ivey Canady interviewed RN Michele Williams regarding pressure injury for R1. Michele stated she had not been to see R1 yet and did not have a look at the injury on Friday. LPA requested RN see the resident at this time. R1 is not on hospice care.

Michele stated pressure injury is a stage 2 pressure ulcer. (Sacral pressure ulcer) Size is 1.4 x .6 (wide) granulation tissue present without signs or symptoms of infection. Resident is doing ok otherwise. Plan of Correction in regard to treatment is home health care. Michele states resident was in the hospital for a different reason. Home health has not responded to inquiries as of yet. The resident care coordinator sent a text message and requested a follow up regarding Resident 1 home health care.

Resident will be seen on 11/09/2022 Nurse Practitioner (NP) Pogorelov. LPA will follow up with NP on 11/09.2022 to ensure healing progression is taking place. LPA requested and received a copy of RN Chart note for today.

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 Sherry Richardson.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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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