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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557005532
Report Date: 12/12/2022
Date Signed: 12/12/2022 03:09:31 PM


Document Has Been Signed on 12/12/2022 03:09 PM - 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:MARK CROWDERFACILITY TYPE:
740
ADDRESS:12877 SYLVA LNTELEPHONE:
(209) 588-0373
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 98DATE:
12/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Mark Crowder - AdministratorTIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced case management incident inspection visit. LPA explained purpose of visit with administrator.

On approximately 11/19/2022, Resident 1 (R1) was found by Sheriff's Department at approximately 4:00 am near facility. R1 was sent to the local Emergency Room (ER) and had a laceration on head. Staff reported that R1 was in room at approximately 12:30 am on the night shift. Family decided at ER that R1 needed a higher level of care and did not return to facility. R1 was out of the facility up to three and a half hours and no staff noticed R1 had left the facility.

Based on interview with administrator LPA determined no delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility.

The following deficiency was cited per California Code of Regulations, Title 22, Division 6, Chapter 8. Immediate civil penalty of $500.00 was assessed on 12/12/2022.

An exit interview was conducted with Administrator and a copy of this report along with appeal rights, civil penalty, and confidential names list was provided.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
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 12/12/2022 03:09 PM - 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: 12/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2022
Section Cited

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87705(k)(8) Care of Persons with Dementia -
Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility.
This requirement is not met as evidenced by:
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Licensee agrees to submit a written plan ensuring that staff met the care and supervision needs of residents with Dementia. Plan of Correction is due on 12/13/2022
Immediate Civil Penalty of $500.00 is being issued on 12/12/2022.
Arielle Pascul
arielle.pascul@dss.ca.gov
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The licensee did not ensure that staff met the care and supervision needs of R1 who eloped from facility. This poses an immediate health and safety 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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2022
LIC809 (FAS) - (06/04)
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