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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557005532
Report Date: 09/09/2022
Date Signed: 10/12/2022 10:23:20 AM


Document Has Been Signed on 10/12/2022 10:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
557005532
ADMINISTRATOR:CATHY HELTONFACILITY TYPE:
740
ADDRESS:12877 SYLVA LNTELEPHONE:
(209) 588-0373
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 102DATE:
09/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Executive Director, Mark CrowderTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Sarah Hurt conducted a Case Management - Incident visit to the facility on September 9, 2022 at 12:30 p.m. LPA Hurt met with facility Executive Director Mark Crowder and explained the purpose of the visit.


LPA Hurt received an incident report from the facility dated September 2, 2022 documenting a medication error. The incident reports reads on September 2, 2022 at 05:30 p.m. Resident 1 received 1 dose (1mg tablet) of Lorazepam from Medication Technician Staff 1. Resident 1 was given another dose of Lorazepam 1mg at 01:00 a.m.by Staff 1. Resident 1 was prescribed Lorazepam once nightly for agitation on June 13, 2022 by her physician.Staff 1 failed to follow this order. Staff 2 found Resident 1 unresponsive in the memory care dining area on September 3, 2022..Staff 2 attempted to communicate with Resident 1 but her speech was extremely slurred. Resident 1 is still in the hospital.


The following Deficiencies are being cited Per Title 22 Regulations. Exit interview conducted with Executive Director Mark Crowder 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: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
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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Document Has Been Signed on 10/12/2022 10:23 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2022
Section Cited

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87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The following requirement has not been met as evidenced by:
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Staff 1 gave Resident 1 the incorrect dose of medication leading to her hospitalization which poses an immediate health, safety, or personal rights risk to 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: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
LIC809 (FAS) - (06/04)
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