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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552701305
Report Date: 05/06/2025
Date Signed: 05/06/2025 05:22:29 PM

Document Has Been Signed on 05/06/2025 05:22 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 LIVINGFACILITY NUMBER:
552701305
ADMINISTRATOR/
DIRECTOR:		PAIS, VALERIEFACILITY TYPE:
740
ADDRESS:12877 SYLVA LANETELEPHONE:
(209) 288-4630
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY: 135CENSUS: 104DATE:
05/06/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Valarie Pais, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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On 05/06/2025, Licensing Program Analysts (LPAs) Triel Ellen Lindstrom and Renee Campbell arrived unannounced to this facility to conduct a case management visit. LPAs met with Facility Designated Administrator (FDA) Valarie Pais and explained the purpose of the visit. The purpose of this visit was to discuss the 30-day eviction notice issued by the facility against R1 on12/20/2024. On 04/28/2025, the Department issued a statement that it did not support the eviction.

FDA Pais stated that R1 shared a private apartment with her husband. According to FDA Pais, R1’s husband was responsible for the base rent of the apartment and R1 was responsible for an additional fee as the second person in the apartment. FDA Pais stated that when R1’s husband passed away last year, R1 began to be charged the full amount of the rent for the unit, as outlined in the rental agreement. She stated that neither R1 or her Power of Attorney (POA) was sent a notification of the rent increase nor an addendum with this information to sign. LPA Lindstrom inquired about the requests for a smaller, more affordable room that R1’s POA stated she made in a 01/08/2025 email to



NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2025
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SKYLINE PLACE SENIOR LIVING
FACILITY NUMBER: 552701305
VISIT DATE: 05/06/2025
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FDA Pais stated that she told R1's POA that there were no smaller, more affordable rooms available at the time of these requests.

FDA Pais stated that the facility attempted to collect an unpaid balance in August 2024 and that when this attempt was unsuccessful, the facility discussed a 30-day eviction notice with LPA Maja Jensen. At this point in the conversation, FDA Pais brought Carly Taylor, Chief Clinical Officer for Milestone Retirement into the conversation by cell phone. Both FDA Pais and CCO Taylow stated that it was their understanding that LPA Jensen had approved the 30-day eviction notice after reviewing the facility’s draft notice and providing recommendations for change. FDA Pais forwarded email correspondence between herself and LPA Jensen dated 10/02/2024 to LPA Lindstrom, in which LPA Jensen stated, ‘While it does appear to be a legal eviction I did recommend some changes.” Upon review of the facility's revised 30-day eviction notice, LPA Jensen said, "This looks great," in a 10/30/2024 email.

FDA Pais and CCO Taylor stated that it was their understanding that they had followed Department advice in terms of the assistance the facility offered R1 in finding alternate placement by providing the links to resources that LPA Jensen had sent in her 10/02/2024 email, as well as by providing R1's POA with information about two local residential facilities that accept Medicare and Medical. FDA Pais stated that R1’s POA has not made arrangements with an alternate facility nor paid off R1’s unpaid balance.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
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: 05/06/2025
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LPAs Lindstrom and Campbell then discussed with FDA Pais and CCO Taylor what type of assistance R1 needs at this time. LPAs Lindstrom and Campbell recommended that the facility take additional steps to find R1 an alternate placement. FDA Pais stated that the facility will call local facilities to check on availability, help arrange assessments and alternate placement and provide them with the needed clinical information.

FDA Pais stated that the facility will contact the Long-Term Ombudsman for additional guidance on how to support R1.

LPAs Lindstrom and Campbell discussed the three steps that the Department outlined for the facility to follow. These three steps are drafting and getting a signature on an addendum to the original rent agreement that notifies R1 of the new rental agreement amount, making an offer to stay in a shared room at an alternate rate, and making additional efforts to find R1 alternative placement. The facility will consult with their Chief Compliance Officer regarding documentation of these steps and notify the department of any questions they may have. Any documentation shall be emailed to LPA Lindstrom at ellen.lindstrom@dss.ca.gov.

The department may return at a later date to determine if further action is needed.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
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