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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552701305
Report Date: 07/02/2024
Date Signed: 07/02/2024 04:12:25 PM


Document Has Been Signed on 07/02/2024 04:12 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: 111DATE:
07/02/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Valerie PaisTIME COMPLETED:
04:30 PM
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On 7/2/24 at approximately 1:45pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a post-licensing inspection. LPA Jensen met with interim Executive Director Valerie Pais and explained the purpose of today's visit.

LPA Jensen inspected the physical plant including the common areas, kitchen, resident rooms and memory support unit. The facility recently underwent some renovations that include new flooring, new paint and new furniture. The facility was observed to be sanitary and all furniture was in good repair. There was 2 days of perishable food and 7 days of non-perishable food. The Ansul system was last serviced in March of 2024 and is in compliance. The kitchen maintains documentation on residents that require special diets that is readily accessible by the kitchen staff. The resident rooms were equipped with all required furniture. LPA Jensen interacted with several residents during the visit, all of whom stated they are satisfied with the accommodations and care they are receiving. The assisted living section of the facility has call signals in the living area, bedroom and bathroom of each unit. LPA Jensen toured the Memory Support Unit. The memory support unit has a monitoring system in place for resident falls within the individual living units. The bathroom water temperature was measured in a main hall bathroom used by residents at 112 degrees and is in compliance. The thermostat in the main hall was set at 76 degrees and is in compliance. LPA Jensen observed several residents engaged in activities. LPA Jensen observed a large board listing the daily activities that included visits from support animals, chair exercises, Bingo, Pokeno and movie night.

The facility is currently recruiting for an on staff nurse. LPA Jensen reviewed physician reports for residents that are insulin dependent. 1 of 3 residents are unable to administer their own glucose testing and insulin injections. Technical assistance was provided.

The facility was observed to be in substantial compliance. 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: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
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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