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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557005532
Report Date: 08/12/2022
Date Signed: 08/15/2022 01:41:21 PM

Substantiated


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
06/29/2022 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20220629135431
FACILITY NAME:SKYLINE PLACE SENIOR LIVINGFACILITY NUMBER:
557005532
ADMINISTRATOR:ILONA ROZA CORPUSFACILITY TYPE:
740
ADDRESS:12877 SYLVA LNTELEPHONE:
(209) 588-0373
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 97DATE:
08/12/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator , Cathy HeltonTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Insufficient staffing to meet residents' needs
Residents are being left unattended in soiled wet clothing for extended periods
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit on 08/12/2022 to investigate the above allegations. LPA met with Administrator Cathy Helton and explained the purpose of today's visit.

Regarding the allegation insufficient staffing to meet residents' needs. Based on LPA observation, and interviews the facility does not have sufficient staff to meet residents needs. LPA spoke with three facility staff who all stated residents needs are not being met due to the facility being short staffed. Staff stated resident showers, and incontinent care are being skipped due to consistent short staffing. LPA observed one caregiver and 2 med techs on the evening shift for 85 residents in the assisted living area of the facility.Therefore, this allegation is SUBSTANTIATED.

Continued onto 9099C...

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
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-20220629135431
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: 08/12/2022
NARRATIVE
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Continued from 9099...


Regarding the allegation residents are being left unattended in soiled wet clothing for extended periods. Based on LPA interviews the residents are being left unattended in soiled wet clothing for extended periods of time.
Staff stated they recently observed at start of shift a resident was in extremely soiled briefs that were leaking through and it did not appear the resident was checked at all on the previous 8 hour shift. Facility staff interviewed stated residents are at times waiting more than hour for incontinent care. Therefore, this allegation is SUBSTANTIATED.

The allegations noted have been substantiated, meaning that there was a preponderance of evidence to prove that the allegations did occur as alleged.




Exit interview conducted with Administrator Cathy Helton and a copy of this report along with Appeals rights provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220629135431
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: 08/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2022
Section Cited
CCR
87625(a)
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87625 Managed Incontinence(a) The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances:(1) The condition can be managed with any of the following: The follwoing requirement has not been met as evidenced by:
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Administrator will conduct training on incontinent care for all facility staff and submit proof of training to LPA by POC date 8/22/2022.
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Based on LPA interviews facility residents are not being provided timely incontinent care which poses a potential health, safety, or personal rights risk to residents in care,
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Type A
08/15/2022
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (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. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. The following requirement has not been met as evidenced by:
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Administrator will continue to work with recruitment department to encourage people to apply at the facility. Administrator will continue to attend job fairs, and promote the facility on all social media platforms. Administrator will begin some type of accountability program for staff at the facility who consistently call of their regular work shifts. Administrator will send proof of active recruiting to LPA by POC date of 08/15/2022.
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Based on LPA observation, and interviews the facility does not have sufficient staffing to meet resident needs which poses an immediate threat to the health, safety or personal rights of residents in care.
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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3