342701097-1-23-2023-27-AS-KHOS-CNFRV3-20230126122052

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701097
Report Date: 01/23/2023
Date Signed: 01/23/2023 04:46:12 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2022 and conducted by Evaluator Jamie Ivey-Canady

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20221118090329

FACILITY NAME:	SKYPARK MANOR		FACILITY NUMBER:	342701097
ADMINISTRATOR:	RICHARDSON, SHERRY		FACILITY TYPE:	740
ADDRESS:	5510 SKY PARKWAY		TELEPHONE:	(916) 422-5650
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY:	144	CENSUS: 88	DATE:	01/23/2023
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Sherry Richardson		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident was assaulted by another resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)s Jamie Ivey Canady arrived at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by Sherry Richardson.

The investigation was conducted by the Department. The investigation consisted of resident medical and file review, in addition to facility incident reports and file review.

The Department has determined the following as it relates to the allegations: Resident was assaulted by another resident while in care.

Continued on LIC 9099 - C...
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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20221118090329

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 01/23/2023

NARRATIVE

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On 1/19/2023 LPA Ivey Canady reviewed Department findings regarding current allegations. The Department findings are based on resident medical and file reviews along with facility incident reports dated 11/18/2022. According to Department file review and facility documentation, neither R1 or R2 have a history of combative or violent tendencies. Based on medical records and medical test findings, R1 sustained no fractures or injuries due to an altercation that occurred on 11/17/2022. Based on review of facility documents, facility staff carried out the appropriate measures and methods in an attempt to intervene the possibility of an altercation. These measures and methods did include separating the residents when the facility recognized the potential for conflict. Based on record reviews and incident reports, although there were attempts by facility staff to intercept a possible altercation, on 11/17/2022, an altercation did subsequently occur on 11/18/2022 that involved one resident attacking/assaulting another. Therefore, the allegation Resident was assaulted by another resident while in care is Substantiated. Based on Department record review of facility files and resident medical records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Exit interview with Administrator. Appeal rights and report given.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20221118090329

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/23/2023 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall...(1) To be accorded dignity in their personal relationships with staff, residents...This was not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated they will conduct in service training for the staff to ensure staff is consistently successful in keeping residents apart, and submit a sign in sheet to LPA NLT 1/24/2023 via email. If one or the other manages to attack any one else, a request for a 3 day eviction noticed for that resident will be submitted.
	8 9 10 11 12 13 14	Based on interviews and record review, The licensee did not ensure combative residents were consistently kept seperate from the facility community, which poses a potential health and safety risk for residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Jamie Ivey-Canady	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023

LIC9099 (FAS) - (06/04)

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