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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552701305
Report Date: 04/29/2024
Date Signed: 04/29/2024 04:19:33 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
02/08/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240208161140
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: 112DATE:
04/29/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Aimee Jo MattsonTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff do not ensure that resident's hygiene needs are being met.
Facility is charging resident for services not provided.
INVESTIGATION FINDINGS:
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On 4/29/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Executive Director Aimee Jo Mattson and explained the purpose of today's visit.

During the course of the investigation the Department conducted interviews with a Home Health Nurse, the facility Regional Nurse, the Executive Director and resident 1 (R1). The Department also reviewed documentation that includes an Admission Agreement, Needs and Service Plans, Home Health documentation, facility policy, in-service training records, and resident chart notes.

Based on the facility bathing policy, "staff will ensure resident's participation to bathe or shower on a routine basis...Twice weekly and as needed will be scheduled." Based on LPA Jensen's review of the skin observation sheet R1 was bathed 6 times in ten weeks.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
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 6
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
02/08/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240208161140

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: DATE:
04/29/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Aimee Jo MattsonTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Resident developed pressure wounds while in care due to neglect.
INVESTIGATION FINDINGS:
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On 4/29/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Executive Director Aimee Jo Mattson and explained the purpose of today's visit.

During the course of the investigation the Department conducted interviews with a Home Health Nurse, the facility Regional Nurse, the Executive Director and resident 1 (R1). The Department also reviewed documentation that includes an Admission Agreement, Needs and Service Plans, Home Health documentation, facility policy, in-service training records, and resident chart notes.

On 2/8/24 Home Health Certification and Care Plan documentation indicates that resident 1 (R1) had stage 2 pressure wounds. On 2/16/24 Home Health Certification and Care Plan documentation re-evaluates the wounds as traumatic partial skin loss due to urinary incontinence. R1 is ambulatory and was admitted with an assessment of not requiring assistance with toileting.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20240208161140
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: 04/29/2024
NARRATIVE
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 The resident was admitted in September of 2023 but did not have hygiene added to the needs and service plan until January of 2024. Documentation indicates that R1's wounds were miscategorized as pressure wounds but were actually due to urinary incontinence. R1's physician report makes no indication of cognitive impairment for R1. During the course of an interview with R1, R1 denies any neglect by staff. Based on the records reviewed and interviews conducted the allegation of "Resident developed pressure wounds while in care due to neglect" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation my have happened, the preponderence of evidence does not prove it.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20240208161140
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: 04/29/2024
NARRATIVE
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The skin observation sheet also noted that R1's toenails or finger nails or both needed clipping on 5 of 6 forms during the period between 12/6/23 through 2/14/24. On 12/27/23 a Home Health Nurse completed an Outside Agency Documentation form and identified resident hygiene as a concern. During the course of an interview R1 confirmed that she was not assisted with showers twice weekly and that there have been occasions where she has called for assistance with no response for up to an hour. The home health documentation reviewed shows that on multiple occasions, including after hygiene was added to R1's care plan, a home health visit was conducted and R1 was observed to be soiled upon their arrival. Based on interviews conducted and the documentation reviewed the allegation of "Staff do not ensure that resident's hygiene needs are being met" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

The Department also conducted a review of the admission agreement, pre-placement appraisal and 3 needs and service plans. Based on the documentation reviewed and interviews conducted R1 was not receiving 2 showers per week after hygiene services were added and billed under the needs and service plan therefore the allegation of " Facility is charging resident for services not provided" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Deficiencies are bing cited pursuant to the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report, a confidential names list and appeal rights were provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20240208161140
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: 04/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2024
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities
...To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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The Licensee agrees to conduct an in-service training and send proof of completion by POC due date.
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This requirement was not met as evidenced by the documentation reviewed reveals that the resident was being charged for hygiene services that were not being administered. This poses a potential risk to the health, safety and personal rights of residents 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.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20240208161140
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: 04/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2024
Section Cited
CCR
87466
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Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by:
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Effective 2/23/24 the Licensee has filled a vacant health and wellness director position who now provides oversight for the resident care director and memory care director and does all assessment for new residents. No further plan of correction required.
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Based on records reviewed and interviews conducted the facility did not meet the hygiene needs of R1 which lead to the development of open wounds. This poses and immediate risk to the health, safety and personal rights of residents 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.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6