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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552701305
Report Date: 01/08/2025
Date Signed: 01/08/2025 03:03:14 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/08/2025 03:03 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/
DIRECTOR:		PAIS, VALERIEFACILITY TYPE:
740
ADDRESS:12877 SYLVA LANETELEPHONE:
(209) 288-4630
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY: 135CENSUS: 103DATE:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Valerie Pais, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 01/08/24, Licensing Program Analyst Renee Campbell arrived to the facility unannounced to complete an annual inspection. LPA Campbell met with Valerie Pais, Administrator (7018063740) and explained the purpose of the visit.

Upon entry, LPA Campbell observed a client playing the piano for other residents who complimented their skill. Staff welcomed LPA Campbell to the facility and directed them to sign in and for a digital fever check.

The facility is a Residential Care Facility for the Elderly and is licensed for clients age 60 and over. The facility has a capacity of 135 non-ambulatory residents. There may be 35 bedridden residents and there is a hospice waiver granted for 12. The building consists of five floors with Memory Care and Assisted Living in their own units. LPA Campbell observed memory care rooms that were furnished appropriately. Bathrooms were in the hall and hot water was measured at 116.9 degrees Fahrenheit (F). Clients in Assisted living had their own bathrooms and hot water was measured at 116.1 degrees which is within the requirement of 105 and 120 degrees F.

In the Assisted Living wing, notes of appreciation from residents were displayed for staff. LPA Campbell observed the dining room in the Memory Care unit. All pathways were free of obstruction.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/08/2025
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Ongoing construction was observed in the non-perishable storage rooms as mentioned in the 11/06/24 812 Notification from the facility. Construction areas included the storage rooms and outside the kitchen entrance. Both areas are staff only and clients are unable to access them. Food service for clients have not been disrupted.

LPA Campbell reviewed the fire drill log for October and November. Fire drill procedures and the sign in sheet for all participants were included. Fire extinguishers were last inspected on 02/07/2024. Thermostats were set at 72 degrees F. There were 5 residents files and 4 staff files that were reviewed and found to be complete.


LPA Campbell consulted with administrator regarding client and staff files. It was suggested that files be consistent in organization and a checklist of items to be file was provided to ensure files were complete. Administrator was also reminded to continually update the Guardian Roster for the facility and remove staff who are no longer employed with them.

Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted with Valerie Pais, Administrator and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025
LIC809 (FAS) - (06/04)
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