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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003429
Report Date: 08/11/2021
Date Signed: 08/11/2021 02:36:14 PM

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: 83DATE:
08/11/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Susan McClureTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit. Community Care Licensing (CCL) received notice that resident #1 (R1) was sent to diaylisis with unkept hygiene.

LPA interviewed Administrator, Caregiver, Transportation Driver, and staff at the Davita Florin Dialysis on 8/4/21.

On 7/22/21, R1 arrived to dialysis with poor hygiene such as feces on wheelchair and soiled pants. On 7/24/21, R1 arrived to dialysis disoriented, eyes closed and unable to respond. 911 was activated and R1 was diagnosed with Sepsis.

The investigation revealed that R1 preferred to manage personal hygiene, however, R1 was diagnosed with dementia and needed assistance with activities of daily living. The assistance was not provided prior to R1 going to appointment.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. Susan McClure was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of the report was given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
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: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2021
Section Cited

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Definitions
"Basic Services," as defined in Health and Safety Code section 1569.312, means those services required to be provided by the facility in order to obtain and maintain a license and include, in such combinations as may meet the needs of the residents and be applicable to the type of facility to be operated, the following: safe and healthful living accommodations; personal assistance and care; observation and supervision; planned activities; food service; and arrangements for obtaining incidental medical and dental care.
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This requirement is not met as evidenced by: The resident arrived to dialysis with self and wheelcahir soiled.
Based on interviews resident's hygiene was not maintained properly
This violation 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021
LIC809 (FAS) - (06/04)
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