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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552701305
Report Date: 12/28/2023
Date Signed: 12/28/2023 01:03:17 PM


Document Has Been Signed on 12/28/2023 01:03 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:MATTSON, AIMEE JOFACILITY TYPE:
740
ADDRESS:12877 SYLVA LANETELEPHONE:
(209) 288-4630
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 116DATE:
12/28/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Aimee Jo MattsonTIME COMPLETED:
01:15 PM
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On 12/28/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue the pre-licensing visit commenced on 12/12/23. LPA Jensen met with Executive Director Aimee Jo Mattson and explained the purpose of today's visit.

During the pre-licensing visit conducted on 12/12/23, LPA Jensen requested that the facility ensure all chemicals or cleaning solutions be locked and inaccessible to clients in care. LPA Jensen also requested a diabetic care plan be submitted for Department review.

LPA Jensen received and reviewed the diabetic care plan and determined it to be in compliance. In addition the facility has contracted with a medical doctor for in house services commencing on 1/4/24. In addition LPA Jensen reviewed Physician communication forms for current residents requesting new orders clarifying the diabetic management need for assistance specifics.

LPA Jensen toured the resident rooms to check for storage of cleaning solutions and found the rooms to be in compliance. LPA Jensen checked the laundry facility and found it to be secured.

The facility was observed to be in substantial compliance and has passed the pre-licensing inspection.

A component III presentation was conducted. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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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