361800227-4-7-2025-56-AS-MMAE-DFHR9W-20250407125014

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361800227
Report Date: 04/07/2025
Date Signed: 04/07/2025 12:50:40 PM

Document Has Been Signed on 04/07/2025 12:50 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SKYLINE VILLA		FACILITY NUMBER:	361800227
ADMINISTRATOR/ DIRECTOR:	RUBEN LICEA		FACILITY TYPE:	740
ADDRESS:	20276 MAJESTIC DR		TELEPHONE:	(760) 240-0730
CITY:	APPLE VALLEY	STATE: CA	ZIP CODE:	92308
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	04/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Ruben Licea		TIME VISIT/ INSPECTION COMPLETED:	12:55 PM

NARRATIVE

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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a comprehensive annual inspection. LPA met with Staff, Hilda Bocanegra, was granted entry and discussed the purpose for the visit. Administrator, Ruben Licea, arrived towards the end of the inspection. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (8), and a current census of (5). LPA conducted a general inspection of facility, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor activity space supplies for residents. Outdoor activity space is shaded and enclosed with self-latching gates. The facility is maintained at a temperature of 71 degrees F. Resident bedrooms were furnished with beds, night stands, chairs, bed linen and lighting. Resident bathroom equipment were operating properly and bathrooms were equipped with grab rails and slip mats. The hot water temperatures in the bathrooms measured at 105 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms, fully charged fire extinguishers, laundry equipment, and telephone service. Sharps were kept in a locked cabinet. LPA observed disinfectant wipes left unattended in the front lobby. Medications were kept in a locked cabinet. Current list of resident medications was not provided when requested during LPA's inspection. The administrator stated via telephone that he has the list on computer. The facility has posted in a common area Community Care Licensing complaint poster, Ombudsman poster, facility license, evacuation plan and emergency telephone numbers. The facility has a designated office where resident files are stored.

Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply was sufficient for number of residents in care. Cups and plates were sufficient for number of residents in care. The facility’s refrigerator and freezer were operating properly.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SKYLINE VILLA	FACILITY NUMBER: 361800227
	VISIT DATE: 04/07/2025

NARRATIVE

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Record Review: The facility has a disaster plan for review. Resident files were reviewed for admissions agreements, physician’s reports, appraisals, emergency contact list, and care plans. Resident #1 (R1) did not have a complete physician's report with primary diagnosis, ambulatory status, mental and physical condition, and tuberculosis results in their file for review. Staff files were reviewed for CPR/first aid and job related training, criminal records clearances/exemptions, and health screenings. Staff #1 (S1) did not first aid training and job related training records in their file for review. The Administrator stated via telephone that he has training available to print out on the computer.

During today's visit, Deficiencies and advisories were issued per title 22 of the California Code of Regulations. An exit interview was conducted were this report was discussed and copy provided with appeal rights to Administrator Licea at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/07/2025 12:50 PM - 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SKYLINE VILLA	FACILITY NUMBER: 361800227
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87458(c)(5)

Medical Assessment

(c) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101, Definitions, or bedridden as defined in Health and Safety Code section 1569.72. The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition, or both. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above by not maintaining a completed physician's report for resident #1 (R1) on file review; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	The licensee shall submit a statement of understanding of regulation cited to the licensing agency by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/07/2025 12:50 PM - 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SKYLINE VILLA	FACILITY NUMBER: 361800227
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87412(c)

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by not maintaining record of Staff #1 (S1's) job relating trainings for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	The Licensee shall submit a statement of understanding of regulation cited to the licensing agency by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/07/2025 12:50 PM - 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SKYLINE VILLA	FACILITY NUMBER: 361800227
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87458(c)(1)(A)

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above by not maintaining a completed physician's report for Resident #1 (R1) with Tuberculosis results on file review; which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	The licensee shall submit a statement of understanding of regulation cited to the licensing agency by POC due date.

Type B

Section Cited

CCR

87465(a)(6)

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by not maintaining record of current resident's medications for LPA review; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2025
	Plan of Correction
1 2 3 4	The Licensee shall submit a statement of understanding on the regulation cited to the licensing agency by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 248-0349
Magda Malcore	TELEPHONE: 951-248-0316
	DATE: 04/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025

LIC809 (FAS) - (06/04)

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