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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552701305
Report Date: 11/07/2024
Date Signed: 11/07/2024 03:50:16 PM

Document Has Been Signed on 11/07/2024 03:50 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: DATE:
11/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Valerie PaisTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 11/7/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management regarding some recent incidents. LPA Jensen met with Executive Director Valerie Pais and explained the purpose of today's visit.

The facility recently experienced a plumbing issue. Plumbers were called immediately upon recognizing the problem. The plumbers were able to identify the cause of the issue. The insurance company was called and determined the issue to be a covered a loss and action was initiated to mitigate damages and complete any necessary repairs. A letter was sent to all resident responsible parties prior to work commencing and Licensing was notified in a timely manner. LPA Jensen toured the areas being worked on and observed appropriate measures being taken to ensure the safety of residents. All work areas are adequately cordoned off and tools and toxins are being kept inaccessible to residents in care.

LPA Jensen also discussed an incident that was reported wherein a spouse visiting a resident was observed by a care provider physically abusing the resident. No significant injuries were sustained by the resident. The care provider took immediate action and notified the med tech on duty. The med tech called the Sheriff who responded and a report was taken. The facility also notified the resident's daughter, the resident's physician, the hospice care provider, Adult Protective Services and the Ombudsman. A temporary protective order was initiated. The resident will be placed on increased monitoring. All reporting was completed in a timely manner and it would appear that all appropriate action was taken by the facility staff.

No deficiencies were observed during the course of this visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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