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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552701305
Report Date: 02/26/2025
Date Signed: 02/26/2025 05:21:48 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/02/2024 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20241002164831
FACILITY NAME:SKYLINE PLACE SENIOR LIVINGFACILITY NUMBER:
552701305
ADMINISTRATOR:MATTSON, AIMEE JOFACILITY TYPE:
740
ADDRESS:12877 SYLVA LANETELEPHONE:
(209) 288-4630
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 104DATE:
02/26/2025
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Valerie Pais, AdministratorTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Facility staff did not provide timely medical care
INVESTIGATION FINDINGS:
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On 02/26/25, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to present findings regarding a Complaint. LPA Campbell met with Valerie Pais and explained the purpose of the visit.

Regarding the allegation that staff did not provide timely medical care, on 09/10/24, a complaint was filed with the Department alleging neglect/lack of care and supervision. During the course of the investigation, the Department conducted interviews with staff and reviewed files for S4 and R1. When interviewed, staff reported that S4 did not check on R1 and other residents when requested due to COVID-19. Based on these findings, it was SUBSTANTIATED that staff did not provide timely medical care.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20241002164831
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/26/2025
NARRATIVE
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A civil penalty in the amount of $500 is hereby assessed due to a violation resulting in injury to a resident, as described above and is cited on the LIC 421IM page. Additional civil penalties are currently being evaluated by the Department, pursuant to Health and Safety Code § 1569.49(f). An exit interview was held with Valerie Pais, Administrator . Appeal rights, a copy of the civil penalty assessment, and a copy of this report were left with Valerie Pais.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20241002164831
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/10/2025
Section Cited
HSC
1569.312
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1569.312 Basic services requirements: Every facility required to be licensed ... shall provide at least the following basic services: Monitoring the activities of the residents... to ensure their general health, safety, and well-being. This requirement was not met as evidenced by :
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The facility will conduct in-service training regarding when to call emergency services when the med-tech or other supervisor does not respond. And to remind staff that they cannot decline to provide care during outbreaks. The facility willl provide sign in sheets for this training by POC date.
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Based on interviews and records review, the licensee did not ensure S4 monitored R1 to ensure R1’s general health and safety which poses an immediate Health, Safety and Personal Rights risk to persons 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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3