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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003429
Report Date: 11/13/2020
Date Signed: 11/13/2020 09:28:15 AM

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:SKY PARK GARDENSFACILITY NUMBER:
347003429
ADMINISTRATOR:SHERRY RICHARDSONFACILITY TYPE:
740
ADDRESS:5510 SKY PARKWAYTELEPHONE:
(916) 422-5650
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:144CENSUS: 80DATE:
11/13/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Sherry RichardsonTIME COMPLETED:
09:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Suong Teh contacted the facility on this day via telephone to conduct a Case Management. This visit was conducted by telephone in lieu of a physical visit due to the current COVID-19 precautions. LPA spoke with the facility administrator Sherry Richardson and explained the purpose of the visit.

On 08/12/2020, the facility submitted an incident report and an SOC 341 reporting on 08/09/2020, Medication Aide #1(MA #1) reported that Resident #1 (R1) had vomited black liquid incident @~12:50 AM. Per report, MA #1 stated to clean R1 and asked whether R1 wanted to go to the ER. Per report, MA #1 reported that R1 declined. The report stated that @4:35 AM R1 was checked and discovered that he was unresponsive and 9-1-1 was contacted.

Based on interviews and records reviewed, the Department has determined that there is sufficient evidence that the staff at Sky Park Gardens did not call 9-1-1 at the onset of R1’s medical distress. Interviews learned that MA#1 admitted that she did not follow the facility policy by ensuring hourly checks of R1.

Facility's failure to adhere to the regulations lack of care and supervision poses an immediate health and safety risk to resident in care.

The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6, Section 87456 Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified. Licensee unable to sign. Additionally, LPA sent a copy of the appeal rights. A copy of this report has been emailed to the facility and the administrator was advised that a signed copy of this report shall be emailed to LPA.

During today’s facility televisit on 11/13/2020, the facility has been advised that under H&S Code §1569.49 the issuance of a Civil Penalty is currently under review and may be assessed at a later date, due to neglect/and lack of supervision of resident while in the care of the facility.

SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6803
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SKY PARK GARDENS
FACILITY NUMBER: 347003429
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2020
Section Cited

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87465(g) Incidental Medical and Dental Care:
The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified [...]
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This requirement was not met as evidenced by interviews and documents reviewed. Staff at Sky Park Gardens did not call 9-1-1 at the onset of R1’s medical distress. This poses an immediate health and safety 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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6803
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2020
LIC809 (FAS) - (06/04)
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