557005532-5-18-2021-27-AS-LKIG-C3VSD8-20210611134645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 557005532
Report Date: 05/18/2021
Date Signed: 05/18/2021 12:44:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/11/2021 and conducted by Evaluator Michael Bilger

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210511131605

FACILITY NAME:	SKYLINE PLACE SENIOR LIVING		FACILITY NUMBER:	557005532
ADMINISTRATOR:	KERRY TWEEDY		FACILITY TYPE:	740
ADDRESS:	12877 SYLVA LN		TELEPHONE:	(209) 588-0373
CITY:	SONORA	STATE: CA	ZIP CODE:	95370
CAPACITY:	135	CENSUS: 105	DATE:	05/18/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jacob Primeau, Administrator		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Staff not showering residents

INVESTIGATION FINDINGS:

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LPA Michael Bilger arrived at the facility at 9:00am to conduct an unannounced complaint visit to the facility today to open a complaint investigation for the allegation listed above. LPA met with Jacob Primeau, Administrator and advised him of the purpose of LPA's visit.

LPA requested the following documents necessary for this investigation: Current Staff roster (LIC 500), Current Resident roster, staffing schedule for May of 2021, actual hours worked by staff for May of 2021, copy of the shower schedule for May 2021, and copy of proof of showers given. From 9:30am to 10:30am LPA interviewed 6 residents in the AL unit. From 10:30am to 11:00am LPA interviewed 3 staff members. 4 of the 6 residents stated that showers are not being given regularly and facility is generally “short-staffed.” 2 of 3 staff members stated during the interview that they feel facility is “short-staffed” occasionally. LPA interviewed Administrator at 9:05am who stated the current census is 105 with 5 caregivers on duty and occasional assistance from med techs and other departments as necessary.
(Cont. on 9099c)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210511131605

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SKYLINE PLACE SENIOR LIVING	FACILITY NUMBER: 557005532
	VISIT DATE: 05/18/2021

NARRATIVE

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Shower schedule was reviewed which indicates residents who require assistance with showers should be receiving showers 3 times per week. Administrator was unable to furnish a document indicating exactly when residents received their showers. Based on the results of today’s visit, deficiencies are being cited under Title 22 regulation, Division 8.

A copy of this report with appeal rights was left with Administrator.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20210511131605

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SKYLINE PLACE SENIOR LIVING	FACILITY NUMBER: 557005532
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/18/2021 Section Cited CCR 87464(f)(1)(c)	1 2 3 4 5 6 7	Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).Health and Safety Code section 1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for..ongoing assistance with...personal care.	1 2 3 4 5 6 7	Administrator to provide to LPA a plan for meeting all residents' shower needs by POC due date. Administrator to provide to LPA written proof that residents have received showers as per shower schedule.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and record reviews, 4 of 6 residents did not receive showers as per recent shower schedule. Licensee did not ensure that showers took place This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 06/18/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports	1 2 3 4 5 6 7	Administrator to provide to LPA a written plan to ensure adequate and sufficient staffing is available to meet the basic needs of residents in care. Plan due by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on resident interviews and staffing interviews, licensee did not ensure adequate and sufficient staffing to meet showering needs of 4 of 6 residents. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC9099 (FAS) - (06/04)

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