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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701097
Report Date: 11/16/2022
Date Signed: 11/17/2022 10:31:53 AM


Document Has Been Signed on 11/17/2022 10:31 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
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:
11/16/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:13 PM
MET WITH:Ashika KaurTIME COMPLETED:
02:44 PM
NARRATIVE
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LPA Albert Johnson made an unannounced POC visit to the facility to verify correction of citations issued during the case management visit conducted on 10/31/2022.

LPA toured the facility, reviewed document submitted for plans of correction observed that the deficiency cited have been cleared.

Deficiency cited under Title 22 Regulations have been cleared. Licensee complied with the terms of the POC by POC due date.

Facility was provided POC cleared letter.

During the POC visit LPA reviewed the chart for R1 and observed a staging of R1's pressure injury as a stage 3 on 11/14/2022. The facility has not request an exception for this and as a result will be given a citation on the attached 809D page.

Exit interview conducted,appeal rights given and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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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Document Has Been Signed on 11/17/2022 10:31 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited

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Exception for Health Conditions: The licensee may submit a written exception if she/he agrees the resident has a prohibited health condition but believes that the intent of the law can be met through alternative means. Written request shall include... documentation of resident’s health condition…licensee’s plan for ensuring the resident’s health related needs can be met by the facility.

This requirement is not met as evidenced by:
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Based on interview and review of medical record on 10/04/2022 and medical discharge
paperwork, the licensee/staff failed to seek an exception as required to retained R1 with a
prohibited health condition. This posed a health and safety risk to resident’s in
care.
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By close of business on 11/17/2022

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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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