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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 03:05:25 PM

Document Has Been Signed on 01/08/2025 03:05 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:
01/08/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Valerie Pais, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 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.

On 12/30/24, an Unusual Incident Report (UIR) was received regarding a possible sexual assault that occurred. On 12/28/24 staff responded to R1’s cries for help from their room and their room alarm. Staff 1 (S1) found R1 laying on the bed with R2 on top of them.

While R2 was assessed at the hospital, there is no report of medical care for R2. Because the UIR does not clarify if there was an attempted sexual assault, LPA Campbell conducted a case management. When contacted, R1’s responsible party (R3) reported that R2 had many incidents of attempting to go into R1’s and other residents’ rooms and lay on their beds or stare out their windows.

On the day of the incident on 12/28/24, when R3 arrived, R1 had fallen asleep and R3 refused further medical care. R3 reported that R1 did not remember the incident and R3 did not believe R1 had been sexually assaulted.

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)
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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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Per S2, when R2 attempted to strangle a staff member. The facility then sent R2 to the hospital for reassessment and prepared to submit an eviction request to licensing. However, before that occurred, the hospice case worker found a new placement. R2’s family then came and removed his belongings the next day.

R2 was removed soon after this incident due to violent outbursts with staff. Before R2's removal, the administrator consulted with licensing staff and attempted to change medication, care plans and use 1 on 1 care.

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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