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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552701305
Report Date: 12/02/2024
Date Signed: 12/02/2024 03:12:49 PM

Unfounded


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
11/27/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20241127112128
FACILITY NAME:SKYLINE PLACE SENIOR LIVINGFACILITY NUMBER:
552701305
ADMINISTRATOR:PAIS, VALERIEFACILITY TYPE:
740
ADDRESS:12877 SYLVA LANETELEPHONE:
(209) 288-4630
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 109DATE:
12/02/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Valerie PaisTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff served unsafe food
INVESTIGATION FINDINGS:
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On 12/2/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation in to the above listed allegation. LPA Jensen met with Executive Director Valerie Pais and explained the purpose of today's visit.

LPA Jensen interviewed the Executive Director who advised that residents began presenting with gastrointestinal (GI) symptoms on 11/26/24 in the PM. By 11/29/24 there were 26 residents and 13 staff members with GI symptoms. As of this date there are 33 residents with GI symptoms and 25 staff. Residents are returning from the hospital with discharges paperwork that states they have an unspecified gastrointestinal virus. In the presence of LPA the Executive Director contacted the Administrative Director of Acute Services with Adventist hospital who confirmed that stool samples were taken from some residents and a panel of testing was conducted to rule out food bourne illness. Tests to date have come back negative for food bourne illness.
Continued on LIC 9099C...
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024
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 2
Control Number 27-AS-20241127112128
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: 12/02/2024
NARRATIVE
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No testing was conducted for Norovirus. LPA Jensen inspected the kitchen. LPA Jensen did not observe any expired food and the area appeared sanitary. Freezer and refrigerator temperatures were within the required range. According to the Executive Director the facility underwent a Crandall audit of the kitchen on 11/29/24 and no deficiencies were observed. The Executive Director will be forwarding this report to the Department by 12/6/24. Based on LPA Jensen's discussion with the Hospital Director who confirmed food bourne illness has been ruled out and based on LPA Jensen's inspection of the kitchen the allegation of Facility staff served unsafe food is UNFOUNDED. A finding of unfounded means the allegation is false, could not have happened, or is without a reasonable basis.

During the course of this visit LPA Jensen is also conducting a case management for the GI symptom outbreak. Based on a conversation with the Administrative Director of Acute Services of the local hospital the cause of the GI outbreak is suspected to be viral. LPA Jensen requested the facility GI illness/Norovirus policy. This policy is dated 3/15/22. LPA Jensen advised that all GI infection control procedures should be implemented effective immediately. The procedures include but are not limited to the following:

-Obtaining a stool culture for verification of Norovirus
-Canceling group activities
-Closing the dining room and implementing room delivery for meals
-Posting "Infectious Outbreak" signs outside of the community to notify visitors
-No new admissions
-Continue all precautions for a full week after last reported case

The facility is also in the process of renovations near the dining area for mold mitigation. LPA Jensen requested the facility obtain air quality readings to retain on file conducted by the vendor contracted with for environmental hazard reduction.

The facility will notify the Department of the results of the Norovirus testing and send a line list to the Department until the outbreak has resolved and they are cleared by Public Health.

No deficiencies are being cited. An exit interview was conducted with the Executive Director and facility Chief Clinical Officer, Carley Taylor.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2