552701305-12-12-2023-27-AS-MJEN-CYG2E2-20231212161912

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 552701305
Report Date: 12/12/2023
Date Signed: 12/12/2023 04:19:49 PM

Document Has Been Signed on 12/12/2023 04:19 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	SKYLINE PLACE SENIOR LIVING		FACILITY NUMBER:	552701305
ADMINISTRATOR:	MATTSON, AIMEE JO		FACILITY TYPE:	740
ADDRESS:	12877 SYLVA LANE		TELEPHONE:	(209) 288-4630
CITY:	SONORA	STATE: CA	ZIP CODE:	95370
CAPACITY:	135	CENSUS: 115	DATE:	12/12/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Aimee Jo Mattson		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/12/23 Licensing Program Analysts (LPAs) Maja Jensen and Kesha Lewis arrived at facility unannounced to conduct a pre-licensing visit for a change in ownership. LPAs Jensen and Lewis met with Executive Director Aimee Jo Mattson and explained the purpose of today's visit. LPA Jensen toured the facility including grounds, physical plant. The grounds were observed to be maintained and all paths were clear of debris. LPA Jensen toured 5 resident rooms and observed all to be equipped with the required furniture including chairs, lamps, and night stand. The water temperature in resident bathrooms and kitchenette was measured at 118 degrees which is in compliance. Unsecured cleaning chemicals were observed in resident room cabinets in the assisted living portion of the facility which included Lysol cleaner, Spray and Wash and Liquid Gold wood cleaner. The laundry room was found to be unlocked. LPA Jensen reviewed the disaster plan and confirmed it to be in compliance. The facility has hard wired smoke detectors and a sprinkler system. The carbon monoxide detector was tested and determined to be in good working order. The fire extinguisher was last serviced in March of 2023 and is in compliance. One end of the building is equipped with a back up generator. The entire building has emergency lighting throughout the common areas. The first aid kit was observed to be complete. All required postings were observed to be displayed in a prominent location. The Pre-Licensing tool was used during the course of this inspection. LPA Jensen toured the kitchen. The facility maintains a 7 day supply of non-perishable food and a 2 day supply perishable food. All food was labeled and no expired food was observed. The kitchen was observed to sanitary. The kitchen chemicals were in a separate locked storage room. The freezer and refrigerator temperature was in compliance. Kitchen staff are appropriately trained and certified. Continued on LIC 809C...

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SKYLINE PLACE SENIOR LIVING	FACILITY NUMBER: 552701305
	VISIT DATE: 12/12/2023

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LPA Jensen inspected the medication room. LPA Jensen asked the medication technician to open the locked medication cart. Syringes were observed in the medication cart. LPA Jensen asked the medication technician if any residents are insulin dependent residents and was advised that there are. LPA Jensen asked who administers the insulin and was advised by the medication technician that residents administer their own insulin with hand over hand assistance by staff. LPA reviewed the LIC 602 for Resident 2 (R2) which states the resident is unable to administer their own medication or injections and cannot conduct their own glucose testing.

The facility has not passed the pre-licensing inspection and has been asked to submit a diabetic care plan and to remove all chemicals from resident rooms. The Executive Director anticipates having completed the requested items no later than 12/22/23.

An exit interview was conducted and a copy of this report, appeal rights and an LIC 811 was provided.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

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