557005532-6-16-2021-27-AS-KHOS-C49N4W-20210623100836

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 557005532
Report Date: 06/16/2021
Date Signed: 06/16/2021 01:25:10 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
06/07/2021 and conducted by Evaluator Sarah Hurt

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210607134615

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: 108	DATE:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Jacob Primeau		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility failed to issue a refund

INVESTIGATION FINDINGS:

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Prior to today’s visit Licensing Program Analyst (LPA) Victoria Brown contacted the Administrator with the following questions:
In the last 10 days, has anyone who is regularly present in the home/facility, including persons in care, or staff developed any of the following symptoms not associated with a pre-existing condition? (NO)
• Fever or chills
• Cough
• Shortness of breath/difficulty breathing
• Fatigue
• Muscle or body aches
• Headaches
• New loss of taste or smell
• Sore throat
See page 9099C for continuation...

Substantiated

Estimated Days of Completion: 30

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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 3

Control Number 27-AS-20210607134615

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: 06/16/2021

NARRATIVE

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• Congestion or runny nose
• Nausea or vomiting
• Diarrhea
Have any individuals Tested positive for COVID-19 with a laboratory confirmed test? NO
Have any individuals Been exposed to someone who tested positive for COVID-19 w/o wearing appropriate PPE? NO Have any individuals Been diagnosed with a respiratory infection (e.g., flu, bronchitis) or have any respiratory symptoms, such as a sinus congestion or runny nose? No Are any individuals in care, caregivers, or staff being evaluated for COVID-19 by a healthcare worker in a healthcare setting? NO Have any individuals in care, caregivers, or staff been quarantined for COVID-19 in the past 30 days? NO Have any individuals in care, caregivers, or staff traveled within the last 14 days, to a country considered to be at high-risk for COVID-19 by the CDC travel website? No

LPA's arrived unannounced on 06/16/2021 at 10:30am to conduct an investigation of the above mentioned allegation. LPA's met with Administrator Jacob Primeau and stated the purpose of the visit.

LPA's requested and reviewed the admissions agreement, the move out guidelines, move out worksheet, death report, LIC 624A, and emails between responsible and the facility.

Resident #1 (R1) passed away on 4/04/2021 and personal property was removed on 4/05/2021. Documentation revealed that R1 paid monthly fees in the amount of $6,062.50. LPA's reviewed Fedex delivery confirmation that refunded fees in the amount of 4,647.92 was delivered to responsible party on 06/09/2021. The investigation revealed that the facility still owes $447.91 to responsible party.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.
An exit interview was conducted with Jacob Primeau and a copy of this report was provided.

See 9099D for continuation...

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20210607134615

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: 06/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/17/2021 Section Cited CCR 87507(5)A1	1 2 3 4 5 6 7	Refund conditions. Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652. Written notice, required pursuant to Health and Safety Code section 1569.652(d), must be made to the individual or entity contractually responsible for the payment of the resident’s fees, if that individual or entity is not also the resident’s responsible person or other individual or individuals as identified in the admission agreement.	1 2 3 4 5 6 7	Licensee shall issue refund by tomorrow 6/17/2021 and proof to be faxed to CCL.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Facility did not issue refund within a timely manner. Based on check not being issued within 15 days as admission agreement stated. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

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